An acute fall in estimated glomerular filtration rate during treatment with losartan predicts a slower decrease in long-term renal function

Abstract

Intervention in the renin-angiotensin-aldosterone-system (RAAS) is associated with slowing the progressive loss of renal function. During initiation of therapy, however, there may be an acute fall in glomerular filtration rate (GFR). We tested whether this initial fall in GFR reflects a renal hemodynamic effect and whether this might result in a slower decline in long-term renal function. We performed a post hoc analysis of the Reduction of Endpoints in Non-Insulin-Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan (RENAAL) trial. Patients assigned to losartan had a significantly greater acute fall in estimated (eGFR) during the first 3 months compared to patients assigned to placebo, but a significantly slower long-term mean decline of eGFR thereafter. A large interindividual difference, however, was noticed in the acute eGFR change. When patients were divided into tertiles of initial fall in eGFR, the long-term eGFR slope calculated from baseline was significantly higher in patients with an initial fall compared to those with an initial rise. When eGFR decline was calculated from 3 months to the final visit, excluding the initial effect, patients with a large initial fall in eGFR had a significant lower long-term eGFR slope compared to those with a moderate fall or rise. This relationship was independent of other risk markers or change in risk markers for progression of renal disease such as blood pressure and albuminuria. Thus, the greater the acute fall in eGFR, during losartan treatment, the slower the rate of long-term eGFR decline. Hence, interpretation of trial results relying on slope-based GFR outcomes should separate the initial drug-induced GFR change from the subsequent long-term effect on GFR.

Structural Predictors of Loss of Renal Function in American Indians with Type 2 Diabetes

“…These findings were confirmed in a cohort of Japanese patients with type 2 diabetes who were followed for 11 years after a protocol kidney biopsy (9). RAS inhibition affects GFR both acutely and chronically (40,41). The acute effect lowers GFR during the first 1-3 months of treatment; the chronic effect slows the rate of GFR decline, and the magnitude of this effect increases with increasing duration of treatment (41).…”

Diabetic Kidney Disease: A Report From an ADA Consensus Conference

“…Studies using RAAS-blocking agents generally show an acute reduction in eGFR, which is thought to be due to a reduction in glomerular hyperfiltration (7). One post hoc analysis of a RAAS antagonist has shown a significant inverse relationship between reduction of eGFR at 6 months and subsequent rate of loss of eGFR (8). In other words, the greater the initial reduction in eGFR, the lower the rate of later eGFR loss.…”

Nefroprotección en una unidad de especialidades médicas de enfermedades crónicas en México

“…Los datos arrojados colocaron a la diabetes mellitus II como la principal causa con 48.5%; la hipertensión arterial sistémica en segundo con 19%; las glomerulonefritis con 12.7% y otras causas con 19.8%. 1 Es importante resaltar que la prevalencia de hipertensión arterial y enfermedad renal crónica casi duplica la prevalencia proporcionada por el IMSS en 2010, por lo que es deber de las autoridades correspondientes identificar las posibles causas de este elevación en la prevalencia e implementar medidas preventivas o correctivas, según sea el caso, con la finalidad de seguir brindando atención medica efectiva, adaptando los programas de prevención al tipo de pacientes que se atienden.…”

“…José Luis Serna-Soto, MC, Port, (1) secretaria.medica@hospitalescandon.org Rafael Antonio de Jesús Ortega-Mendoza, MC, Port, (1) Oscar Adrián Rivera-Ramírez, MC, Anest, (1) Guillermo Cesar Pérez-Peláez, MC, Pediatr. (1) ( …”