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Remission of Proteinuria Improves Prognosis in Iga Nephropathy

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Remission of Proteinuria Improves Prognosis in Iga Nephropathy CLINICAL RESEARCH www.jasn.org Remission of Proteinuria Improves Prognosis in IgA Nephropathy Heather N. Reich,* Ste´phan Troyanov,† James W. Scholey,* and Daniel C. Cattran,* for the Toronto Glomerulonephritis Registry *Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, and †Department of Medicine, Division of Nephrology, Hoˆpital du Sacre´-Coeur de Montre´al, Faculty of Medicine, Universite´de Montre´al, Montreal, Quebec, Canada ABSTRACT Proteinuria has been shown to be an adverse prognostic factor in IgA nephropathy. The benefit of achieving a partial remission of proteinuria, however, has not been well described. We studied 542 patients with biopsy-proven primary IgA nephropathy in the Toronto Glomerulonephritis Registry and found that glomerular filtration rate (GFR) declined at Ϫ0.38 Ϯ 0.61 ml/min per 1.73 m2/mo overall, with 30% of subjects reaching end-stage renal disease. Multivariate analysis revealed that proteinuria during follow-up was the most important predictor of the rate of GFR decline. Among the 171 patients with Ͻ1 g/d of sustained proteinuria, the rate of decline was 90% slower than the mean rate. The rate of decline increased with the amount of proteinuria, such that those with sustained proteinuria Ͼ3 g/d (n ϭ 121) lost renal function 25-fold faster than those with Ͻ1 g/d. Patients who presented with Ն3 g/d who achieved a partial remission (Ͻ1 g/d) had a similar course to patients who had Յ1 g/d throughout, and fared far better than patients who never achieved remission. These results underscore the relationship between proteinuria and prognosis in IgA nephropathy and establish the importance of remission. J Am Soc Nephrol 18: 3177–3183, 2007. doi: 10.1681/ASN.2007050526 Primary IgA nephropathy (IgAN) is the most com- in IgAN5,10,17,24,25 and have suggested that much lower mon form of idiopathic glomerulonephritis (GN) levels of proteinuria adversely affect prognosis. Fur- throughout the world and the main cause of ESRD thermore, although the concept of achieving “partial in patients with primary glomerular disease.1 In To- remission” is not commonly associated with IgAN, ronto, nearly 40% of patients with IgAN progress to recent evidence in other forms of GN has determined ESRD by 10 yr.2 Variability in the literature regard- its clinical significance and established its prognostic ing the clinical course of patients with IgAN3–7 may value.26,27 The relevance of such a definition and its be related to multiple factors, including patient bi- value in IgAN would be important for management of ologic differences, nephrologists’ practice patterns this disease. (e.g., biopsy timing), and geography.7 The ability to Accordingly, we examined the effects of protein- CLINICAL RESEARCH predict outcome in patients with IgAN remains a uria at diagnosis as well as sustained exposure to critical feature of patient treatment and has been a 2,3,5,6,8–15 primary focus of previous studies. Received May 1, 2007. Accepted July 4, 2007. Many studies7,16,17 have shown that proteinuria is a Published online ahead of print. Publication date available at predictor of outcome in IgAN. Experimental evidence www.jasn.org. supports these human data by clarifying the direct del- Correspondence: 18–23 Dr. Heather Reich, c/o The Toronto Glomeru- eterious effect of proteinuria on renal tissue. In lonephritis Registry, Toronto General Hospital, 12EN-228, 200 contrast to other progressive types of GN, in which it Elizabeth Street, Toronto, Ontario M5G 2C4, Canada. Phone: seems that only sustained nephrotic-range protein- 416-340-4187; Fax: 416-340-3714; E-mail: [email protected] uria (Ͼ3 to 3.5 g/d) ensures a poor prognosis, studies Copyright © 2007 by the American Society of Nephrology J Am Soc Nephrol 18: 3177–3183, 2007 ISSN : 1046-6673/1812-3177 3177 CLINICAL RESEARCH www.jasn.org proteinuria on outcome in a large cohort of patients who had ysis revealed that several factors, shown in Table 2, were pre- primary IgAN and were followed longitudinally in the Toronto dictive of a faster rate of renal function decline (steeper, more Glomerulonephritis Registry. We also assessed the prognostic negative slope). relevance of achieving partial remission as defined by achiev- The time-average proteinuria (TA-proteinuria; see Concise ing sustained proteinuria values Ͻ1 g/d. Methods section) was a critical determinant of slope by uni- variate and multivariate analysis (P Ͻ 0.01) and the most im- portant predictor of renal function decline (R2 ϭ 0.162, F ϭ RESULTS 104.5, P Ͻ 0.01). Proteinuria at presentation was not predic- tive of slope by multivariate analysis. Baseline Characteristics and Clinical Outcome The TA-proteinuria was also analyzed as a categorical vari- As described in Table 1, the majority (61%) of the 542 patients able, as illustrated in Table 3. When adjusted for multiple com- studied were male and of white or Asian (China, Japan, or parisons, the rate of deterioration (slope) of renal function Pacific Rim) descent. Mean initial proteinuria was 2.4 g/d, and differed significantly across the entire range of proteinuria. creatinine clearance (CrCl) was 77 ml/min per 1.73 m2.Pa- The greatest difference in rate of decline occurred between the tients were followed for 6.5 yr. By study completion, one third Յ1 and Ͼ1 g/d TA-proteinuria. On the basis of the mean 10-yr of patients had reached ESRD. The rate of progression as mea- slope, patients with Յ1 g of TA-proteinuria had stable renal sured by slope of CrCl was Ϫ0.38 Ϯ 0.61 ml/min per 1.73 function, and patients with 1 to2gofTA-proteinuria had a m2/mo (Ϫ4.56 ml/min per 1.73 m2/yr). projected unadjusted loss of 40 ml/min per 1.73 m2 by 10 yr. Trend test and nonparametric testing did not establish differ- Proteinuria and the Rate of Decline of Renal Function ences among patients with Յ1 g/d TA-proteinuria: 0 to 0.3 Clinical variables at onset of disease and during follow-up were (n ϭ 36) versus 0.3 to 0.6 (n ϭ 63) versus 0.6 to 1 g/d TA- tested for association with the slope of CrCl. Regression anal- proteinuria (n ϭ 72; slopes 0.00 Ϯ 0.39, 0.02 Ϯ 0.48, and Ϫ0.06 Ϯ 0.48 ml/min per 1.73 m2/mo, respectively; NS). Pro- Table 1. Baseline characteristics and clinical outcome in teinuria categories did not overlap (i.e., patients were assigned 542 patients with IgAN to only one category of TA-proteinuria). Characteristic Value Baseline Proteinuria and Renal Survival age (yr; mean Ϯ SD ͓range͔) 38.2 Ϯ 13.01 (15.6 to 73.5) The TA-proteinuria was the most important predictor of renal gender (% male) 61 survival, even when corrected for other parameters (multivariate BMI (kg/m2; mean Ϯ SD ͓range͔) 25.9 Ϯ 5 (16 to 43) hazard 1.57; 95% confidence interval 1.39 to 1.77; P Ͻ 0.01). The creatinine (␮mol/L; mean Ϯ SD 129.7 Ϯ 70.6 (50 to 731) graded effect of TA-proteinuria on renal survival is illustrated in ͓range͔) Figure 1. Having Ͻ0.3 g/d proteinuria was similar to 0.3 to 1.0 g/d, MAP (mmHg; mean Ϯ SD ͓range͔) 103 Ϯ 16 (73 to 170) but each gram above 1 g/d (reference group) was associated with Ϯ Ϯ 24-h urine protein (g; mean SD 2.37 2.5 (0 to 22) worse renal survival, with a hazard ratio of 3.5 for ESRD with 1 to ͓ ͔ range ) 2 g/d, 5 with 2 to 3 g/d, and 10 with Ͼ3 g/d. CrCl (ml/min per 1.73 m2; mean Ϯ 77.0 Ϯ 33 (9 to 217) ͓ ͔ We analyzed the course of patients whose initial proteinuria SD range ) Ͼ ethnicity (%) was 1 g/d and fell below this level during follow-up. Patients white 50.4 were divided into groups on the basis of their peak proteinuria: black 2.8 1to2,2to3,andϾ3 g/d. As illustrated in Figure 2, all patients Asian 23.1 whose proteinuria reached a “partial remission” of Ͻ1 g/d, other 10.0 regardless of the starting point, had a similar, favorable survival unknown 13.7 (log rank NS) and rate of progression (Ϫ0.2 Ϯ 0.47, Ϫ0.14 Ϯ Follow-up 0.63, and Ϫ0.16 Ϯ 0.37 ml/min per 1.73 m2/mo respectively; length of follow-up (mo; mean Ϯ SD 78.1 Ϯ 59 (12 to 315) NS). In comparison, the outcome of “nonremitters” (i.e., those ͓ ͔ range ) who did not achieve Ͻ1 g/d) was markedly worse than remit- Ϯ ͓ ͔ Ϯ MAP (mmHg; mean SD range ) 99.7 10 (72 to 141) ters, with a far more rapid rate of renal decline (Ϫ0.76 Ϯ 0.59 peak proteinuria (g/24 h; mean Ϯ SD) 3.71 Ϯ 3.20 versus Ϫ0.13 Ϯ 0.41 ml/min per 1.73 m2/mo respectively; P Ͻ proteinuria (g/24 h; mean Ϯ SD) 2.19 Ϯ 1.94 treatment (%) 0.01). Patients who achieved complete remission of protein- Ͻ ACEi or ARB 53 uria (sustained level of 0.3 g/d with preserved CrCl) did not fish oil 15.1 have a different rate of renal function decline than patients any immunosuppression 15.7 who achieved partial remission to Ͻ1 g/d (Ϫ0.17 Ϯ 0.47 versus prednisone 12.5 Ϫ0.13 Ϯ 0.41 ml/min per 1.73 m2/mo, respectively; NS).
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