Effect of renin-angiotensin-aldosterone system inhibition, dietary sodium restriction, and/or diuretics on urinary kidney injury molecule 1 excretion in nondiabetic proteinuric kidney disease: a post hoc analysis of a randomized controlled trial.
BACKGROUND
Tubulointerstitial damage plays an important role in chronic kidney disease (CKD) with proteinuria. Urinary kidney injury molecule 1 (KIM-1) reflects tubular KIM-1 and is considered a sensitive biomarker for early tubular damage. We hypothesized that a decrease in proteinuria by using therapeutic interventions is associated with decreased urinary KIM-1 levels.


METHODS
Post hoc analysis of a randomized, double-blind, placebo-controlled, crossover trial.


METHODS
34 proteinuric patients without diabetes from our outpatient renal clinic.


METHODS
Stepwise 6-week interventions of losartan, sodium restriction (low-sodium [LS] diet), their combination, losartan plus hydrochlorothiazide (HCT), and the latter plus an LS diet.


METHODS
Urinary excretion of KIM-1, total protein, and N-acetyl-beta-d-glucosaminidase (NAG) as a positive control for tubular injury.


RESULTS
Mean baseline urine protein level was 3.8 +/- 0.4 (SE) g/d, and KIM-1 level was 1,706 +/- 498 ng/d (increased compared with healthy controls; 74 ng/d). KIM-1 level was decreased by using placebo/LS (1,201 +/- 388 ng/d; P = 0.04), losartan/high sodium (1,184 +/- 296 ng/d; P = 0.09), losartan/LS (921 +/- 176 ng/d; P = 0.008), losartan/high sodium plus HCT (862 +/- 151 ng/d; P = 0.008) and losartan/LS plus HCT (743 +/- 170 ng/d; P = 0.001). The decrease in urinary KIM-1 levels paralleled the decrease in proteinuria (R = 0.523; P < 0.001), but not blood pressure or creatinine clearance. 16 patients reached target proteinuria with protein less than 1 g/d, whereas KIM-1 levels normalized in only 2 patients. Urinary NAG level was increased at baseline and significantly decreased during the treatment periods of combined losartan plus HCT only. The decrease in urinary NAG levels was not closely related to proteinuria.


CONCLUSIONS
Post hoc analysis.


CONCLUSIONS
Urinary KIM-1 level was increased in patients with nondiabetic CKD with proteinuria and decreased in parallel with proteinuria by using losartan, sodium restriction, their combination, losartan plus HCT, and the latter plus sodium restriction. These results are consistent with the hypothesis of amelioration of proteinuria-induced tubular damage. Long-term studies are warranted to evaluate whether targeting treatment on KIM-1 can improve outcomes in patients with CKD with proteinuria.
Waanders
Femke
F
Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Vaidya
Vishal S
VS
van Goor
Harry
H
Leuvenink
Henri
H
Damman
Kevin
K
Hamming
Inge
I
Bonventre
Joseph V
JV
Vogt
Liffert
L
Navis
Gerjan
G
D000118:Acetylglucosaminidase / Q000652:urine; D000328:Adult; D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use; D015415:Biomarkers / Q000652:urine; D002908:Chronic Disease; D003131:Combined Modality Therapy; D018592:Cross-Over Studies; D004232:Diuretics / Q000494:pharmacology / Q000627:therapeutic use*; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005260:Female; D000072596:Hepatitis A Virus Cellular Receptor 1; D006801:Humans; D006852:Hydrochlorothiazide / Q000627:therapeutic use; D007674:Kidney Diseases / Q000188:drug therapy / Q000503:physiopathology / Q000652:urine*; D019808:Losartan / Q000627:therapeutic use; D008297:Male; D008562:Membrane Glycoproteins / Q000652:urine*; D008875:Middle Aged; D011507:Proteinuria / Q000188:drug therapy / Q000503:physiopathology / Q000652:urine*; D011991:Receptors, Virus; D012084:Renin-Angiotensin System / Q000187:drug effects / Q000502:physiology*; D012982:Sodium, Dietary / Q000494:pharmacology / Q000627:therapeutic use*; D016896:Treatment Outcome
D000959:Antihypertensive Agents; D015415:Biomarkers; D004232:Diuretics; C491143:HAVCR1 protein, human; D000072596:Hepatitis A Virus Cellular Receptor 1; D008562:Membrane Glycoproteins; D011991:Receptors, Virus; D012982:Sodium, Dietary; D006852:Hydrochlorothiazide; D000118:Acetylglucosaminidase; D019808:Losartan