Nephrotic Proteinuria Without Hypoalbuminemia: Clinical Characteristics and Response to Angiotensin-Converting Enzyme Inhibition

Praga, Manuel; Borstein, Belen; Andres, A.; Arenas, Joaquı́n; Oliet, Aniana; Montoyo, C.; Ruilope, Luís M.; Rodicio, José L.

doi:10.1016/s0272-6386(12)80483-5

Cited by 75 publications

(39 citation statements)

References 30 publications

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“…In fact, studies by du Buf-Vereijken et al (17) and in a review by Troyanov et al (28), the use of ACEi or ARB by multivariate analysis did not show an independent value in determining the prognosis of patients with MN. Furthermore, Praga et al (39,40) showed that in patients with NS (the majority with MN), ACEi were ineffective in reducing proteinuria and that this response in patients with MN was associated with a poor renal function outcome. (4) In patients in whom a significant antiproteinuric response is observed, the effect is usually seen within 2 mo of initiation of angiotensin II blockade therapy (35).…”

Section: Conservative Therapymentioning

confidence: 99%

Idiopathic Membranous Nephropathy

Fervenza

Sethi

Specks

2008

Clinical Journal of the American Society of Nephrology

133

123

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Idiopathic membranous nephropathy is still the most common glomerular disease associated with nephrotic syndrome. The greater the proteinuria, the greater the long-term risk for renal failure. In addition, patients who have membranous nephropathy with nephrotic syndrome have significant morbidity and mortality, in particular related to thromboembolic and cardiovascular complications. There is no specific treatment for membranous nephropathy. Supportive care with the use of diuretics and angiotensin-converting enzyme inhibitors in combination with angiotensin II receptor blocker is recommended, but these agents have only a limited effect. Immunosuppressive treatment options include the use of corticosteroids, alkylating agents, cyclosporin A, tacrolimus, and mycophenolate mofetil, but their use is controversial, not all have been shown to be effective, and their use can be associated with significant adverse effects. This has resulted in relatively small improvement in the prognosis of membranous nephropathy in the past 30 yr, with up to 40% of patients eventually reaching end-stage renal failure. Agents that offer more complete response rates with lower adverse effects are truly needed. Recent data suggest that B cells play a key role in the pathogenesis of a number of autoimmune diseases including membranous nephropathy and that selective depletion of B cells in humans may be beneficial in preventing the production of pathogenic immunoglobulins and subsequent renal injury.Clin Case PresentationA 32-yr-old man underwent a general medical examination at his primary care physician's office in February 2004. At that time, he was noted to have elevated total cholesterol of 353 mg/dl and triglycerides of 417 mg/dl and was started on simvastatin 40 mg/d. During the course of the next 2 mo, he started developing swelling in his feet and ankles that proceeded to involve his calves. He also developed tenderness on his left calf. A diagnosis of a deep venous thrombosis was made, and he was started on oral anticoagulant therapy. Given the increased lower extremity edema, a urinalysis was conducted, and the patient was found to have significant proteinuria, with a 24-h urine collection showing proteinuria of 9.3 g. The patient had no history of diabetes, macroscopic hematuria, or hypertension. The patient underwent extensive serologic workup including monoclonal protein studies, serum complement levels, anti-neutrophil cytoplasmic antibodies, hepatitis B and C and HIV serology, and anti-nuclear antibody, all of which were negative or in the normal range, and in July 2004, he was referred to our institution for further evaluation. At presentation at the Mayo Clinic, the physical examination was of a healthy-appearing young man. His BP was 136/87 mmHg, pulse rate was 69, weight was 89.8 kg, and body mass index was 29 kg/m 2 . Eyes, nose, and throat examination was normal.There was no lymphadenopathy. Heart examination showed regular rate and rhythm with no murmurs. Lungs were clear to auscultation. Abdomen was soft, with no ...

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Section: Conservative Therapymentioning

confidence: 99%

Idiopathic Membranous Nephropathy

Fervenza

Sethi

Specks

2008

Clinical Journal of the American Society of Nephrology

133

123

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“…O nce proteinuria occurs and/or chronic renal failure develops, the rate of decline of renal function in diabetic nephropathy is considerably higher than the rate in other renal diseases (1)(2)(3). We believed that patients with diabetes suffer a faster decline of renal function than subjects without diabetes, explaining why the number of patients with diabetic end-stage renal failure is increasing (1).…”

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confidence: 98%

Determinants of Decline in Glomerular Filtration Rate in Nonproteinuric Subjects with or without Diabetes and Hypertension

Yokoyama¹,

Kanno²,

Takahashi³

et al. 2009

Clinical Journal of the American Society of Nephrology

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Background and objectives: This study investigated whether the slope of estimated GFR is different between nonproteinuric subjects with and without diabetes, and what clinical factors are associated with the GFR slope.Design, setting, participants, & measurements: An observational cohort study was performed in 923 subjects, and the predictive value of baseline variables on the GFR slope was investigated.Results: On the basis of the median 3-yr follow-up and 7 measurements of GFR, GFR slope (%/yr, median and interquartile range) was significantly larger in subjects with diabetes (؊2.39 (؊4.86 to 0.15), n ‫؍‬ 729) than in those without diabetes (؊1.02 (؊4.28 to 1.37), n ‫؍‬ 194), and this difference remained significant with or without presence of hypertension. After adjustments for confounding factors, predictors of GFR decline were found to be baseline high values of glycosylated hemoglobin A 1C (HbA 1C ), GFR, systolic blood pressure, and low plasma total protein in subjects with diabetes, whereas only the latter two were significant in subjects without diabetes. In subjects with diabetes, the high GFR was accounted for by high HbA 1C at baseline, and the predictors of GFR decline differed between those with and without hypertension, or with high and low baseline GFR. Any combination of the predictors showed increased risk for GFR decline.Conclusions: GFR slope is substantially affected by multiple factors at various stages. The degree of chronic hyperglycemia is likely to play a crucial role in elevating GFR and accelerating the decline in patients with type 2 diabetes even from the normoalbuminuric stage.

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“…Similarly, although the finding of collapsing FSGS may be enough to decide on immunosuppressive therapy, I believe that in other cases the histologic diagnosis is not enough, and additional clinical information (i.e., presence or absence of NS is needed in order to make this decision). Indeed, there are many patients with massive proteinuria that do not develop hypoalbuminemia (72). This is especially true in patients with secondary FSGS (73).…”

Section: Question 2bmentioning

confidence: 99%

American Society of Nephrology Quiz and Questionnaire 2013

Fervenza

Perazella

Choi

2014

Clinical Journal of the American Society of Nephrology

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The Nephrology Quiz and Questionnaire (NQ&Q) remains an extremely popular session for attendees of the Annual Meeting of the American Society of Nephrology. As in past years, the conference hall of the 2013 meeting was overflowing with interested audience members. Topics covered by expert discussants included electrolyte and acid-base disorders, glomerular disease, ESRD/dialysis, and transplantation. Complex cases representing each of these categories, along with single best answer questions, were prepared by a panel of experts. Before the meeting, program directors of United States nephrology training programs answered questions through an Internet-based questionnaire. A new addition to the NQ&Q was participation in the questionnaire by nephrology fellows. To review the process, members of the audience test their knowledge and judgment on a series of caseoriented questions prepared and discussed by experts. Their answers are compared in real time using audience response devices with the answers of nephrology fellows and training program directors. The correct and incorrect answers are then briefly discussed after the audience responses and the results of the questionnaire are displayed. This article recapitulates the session and reproduces its educational value for CJASN readers. Enjoy the clinical cases and expert discussions.

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Nephrotic Proteinuria Without Hypoalbuminemia: Clinical Characteristics and Response to Angiotensin-Converting Enzyme Inhibition

Cited by 75 publications

References 30 publications

Idiopathic Membranous Nephropathy

Idiopathic Membranous Nephropathy

Determinants of Decline in Glomerular Filtration Rate in Nonproteinuric Subjects with or without Diabetes and Hypertension

American Society of Nephrology Quiz and Questionnaire 2013

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