title: Off the beaten renin-angiotensin-aldosterone system pathway: new perspectives on antiproteinuric therapy.
abstract: CKD is a major public health problem in the developed and the developing world. The degree of proteinuria associated with renal failure is a generally well accepted marker of disease severity. Agents with direct antiproteinuric effects are highly desirable therapeutic strategies for slowing, or even halting, progressive loss of kidney function. We review progress on therapies acting further downstream of the renin-angiotensin-aldosterone system pathway (e.g., transforming growth factor-beta antagonism, endothelin antagonism) and on those acting independent of the renin-angiotensin-aldosterone system pathway. In all, we discuss 26 therapeutic targets or compounds and 2 lifestyle changes (dietary modification and weight loss) that have been used clinically for diabetic or nondiabetic kidney disease. These therapies include endogenous molecules (estrogens, isotretinoin), biologic antagonists (monoclonal antibodies, soluble receptors), and small molecules. Where mechanistic data are available, these therapies have been shown to exert favorable effects on glomerular cell phenotype. In some cases, recent work has indicated surprising new molecular pathways for some therapies, such as direct effects on the podocyte by glucocorticoids, rituximab, and erythropoietin. It is hoped that recent advances in the basic science of kidney injury will prompt development of more effective pharmaceutical and biologic therapies for proteinuria.
authors.affiliation: Division of Nephrology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
authors.forename: Judit
authors.initials: J
authors.lastname: Gordon
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Kopp
mesh_terms: D000818:Animals; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use; D065095:Calcineurin Inhibitors; D016232:Endothelins / Q000037:antagonists & inhibitors; D004921:Erythropoietin / Q000627:therapeutic use; D015525:Fatty Acids, Omega-3 / Q000008:administration & dosage; D005247:Feeding Behavior / Q000187:drug effects; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007674:Kidney Diseases / Q000178:diet therapy / Q000188:drug therapy*; D051379:Mice; D011507:Proteinuria / Q000178:diet therapy / Q000188:drug therapy*; D051381:Rats; D012084:Renin-Angiotensin System / Q000187:drug effects*; D000069283:Rituximab; D015291:Transforming Growth Factors / Q000037:antagonists & inhibitors; D015431:Weight Loss / Q000187:drug effects / Q000502:physiology
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D000959:Antihypertensive Agents; D065095:Calcineurin Inhibitors; D016232:Endothelins; D015525:Fatty Acids, Omega-3; D005938:Glucocorticoids; D004921:Erythropoietin; D000069283:Rituximab; D015291:Transforming Growth Factors