title: Conservative management of chronic kidney disease stage 5: role of angiotensin converting enzyme inhibitors.
abstract: BACKGROUND
  Benefits and risks of angiotensin converting enzyme inhibitors (ACE-I) in advanced chronic kidney disease (CKD) are controversial. We tested the role of ACE-I in slowing the progression of renal damage in a real-world elderly population with CKD stage 5.
  
  
  METHODS
  We evaluated all patients consecutively referred to our CKD stage 5 outpatient clinic from January 2002 to December 2013. Chronicity was defined as two consecutive estimated glomerular filtration rate (eGFR) measurements below 15 ml/min/1.73 m2. We retrieved parameters of interest at baseline and assessed eGFR reduction rate during follow-up. We estimated GFR by the 4-variable Modification of Diet in Renal Disease (MDRD) formula.
  
  
  RESULTS
  Mean age of the 342 subjects analyzed was 72 years and eGFR 10 ml/min/1.73 m2. In the 188 patients on ACE-I at baseline, the subsequent annual rate of eGFR reduction was less than a third of that found in the 154 patients off ACE-I. Across phosphate quartiles, baseline eGFR significantly decreased while its annual reduction rate significantly increased. Of the original cohort, 60 patients (17 %) died, 201 (59 %) started dialysis and 81 (24 %) were still in conservative treatment at the end of the study. Multivariate analysis identified age, phosphate, proteinuria, baseline eGFR and its rate of progression as independent risk factors directly or inversely predictive of progression to dialysis. ACE-I use significantly reduced by 31 % the risk of dialysis.
  
  
  CONCLUSIONS
  Our study shows that proteinuria independently predicts further renal damage progression even in end-stage renal disease patients not yet in dialysis. In our cohort of elderly patients with very advanced CKD, ACE-I was effective in slowing down further renal damage progression.
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy. pierodattolo@tin.it.
authors.forename: Pietro C
authors.initials: PC
authors.lastname: Dattolo
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Pamela
authors.initials: P
authors.lastname: Gallo
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Michelassi
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Nunzia
authors.initials: N
authors.lastname: Paudice
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Rossella
authors.initials: R
authors.lastname: Cannavò
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Romoli
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Filippo
authors.initials: F
authors.lastname: Fani
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Aris
authors.initials: A
authors.lastname: Tsalouchos
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Alma
authors.initials: A
authors.lastname: Mehmetaj
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Ferro
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Sergio
authors.initials: S
authors.lastname: Sisca
authors.affiliation: Nephrology Unit, Santa Maria Annunziata Hospital, via Dell'Antella 58, Bagno a Ripoli, Florence, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Pizzarelli
mesh_terms: D000368:Aged; D000553:Ambulatory Care; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D015415:Biomarkers / Q000097:blood; D016009:Chi-Square Distribution; D018450:Disease Progression; D005260:Female; D005919:Glomerular Filtration Rate / Q000187:drug effects; D006801:Humans; D007558:Italy; D007668:Kidney / Q000187:drug effects* / Q000201:enzymology / Q000503:physiopathology; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000188:drug therapy* / Q000201:enzymology / Q000503:physiopathology; D008297:Male; D015999:Multivariate Analysis; D010710:Phosphates / Q000097:blood; D016016:Proportional Hazards Models; D011507:Proteinuria / Q000175:diagnosis / Q000188:drug therapy* / Q000201:enzymology / Q000503:physiopathology; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000188:drug therapy* / Q000201:enzymology / Q000503:physiopathology; D012084:Renin-Angiotensin System / Q000187:drug effects*; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D015415:Biomarkers; D010710:Phosphates
keywords: ACE-Inhibitors; Chronic kidney disease; Conservative management; Dialysis