Angiotensin inhibition or blockade for the treatment of patients with quiescent lupus nephritis and persistent proteinuria

Abstract

Angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) reduces proteinuria and the rate of renal function deterioration in diabetic nephropathy and other glomerular diseases, but its role in quiescent lupus nephritis has not been established. We conducted a retrospective study to investigate the effects of ACEI/ARB on proteinuria and renal function in patients with persistent proteinuria (>1 g/day) despite resolution of acute lupus nephritis following immunosuppressive treatment. Fourteen out of 92 patients were included. The duration of treatment with ACEI/ARB was 52.1 +/- 35.7 months. The levels of proteinuria, serum albumin, serum creatinine, systolic and diastolic blood pressure were 1.10 to 6.90 g/day, 35.8 +/- 3.6 g/L, 102.54 +/- 34.48 micromol/L, 137.6 +/- 10.9 and 81.9 +/- 9.2 mmHg at baseline. Proteinuria and serum albumin showed significant sustained improvements after 6 and 24 months of treatment. Comparison of slopes for serial proteinuria, albumin and reciprocal of serum creatinine before and after treatment showed significant improvements in six (43%), eight (57%) and two patients, respectively. At last follow-up proteinuria remained significantly lower (0.36 g/day, P = 0.043) and albumin higher (41.3 +/- 2.2 g/L, P = 0.023). Eleven (78.6%) patients had proteinuria improved by >50%, and five had insignificant proteinuria at last follow-up. Systolic blood pressure was significantly reduced from 6 months onwards, but this did not correlate with proteinuria reduction. Diastolic blood pressure, serum creatinine, creatinine clearance, anti-dsDNA, C3 and haemoglobin were not altered. We conclude that ACEI/ARB effectively reduces proteinuria and improves serum albumin in patients with persistent proteinuria despite quiescent lupus nephritis.

Investigation of pathological and clinical features of lupus nephritis in 73 autopsied cases with systemic lupus erythematosus

“…There have been reports that IVCY results in the progression of chronic renal indices [27,28], potentially leading to a decreased quality of life (QOL) due to renal impairment and chronic renal failure caused by sclerotic lesions, or to limited therapeutic agent options, if not the loss of renal function. Angiotensin blockade has been reported to be effective at alleviating proteinuria in cases of inactive LN [29] and it may help combat chronic sclerotic lesions, but there have been no reports of histological evidence of improvement in sclerotic lesions to date. Treatment of sclerotic lesions will likely be an issue that will need to be addressed in the future.…”

Європейські Доказові Рекомендації По Діагностиці Та Лікуванню Люпус-Нефриту У Дітей: Ініціатива SHARE

“…Several studies have reported on the anti-proteinuric effect of angiotensin-I converting enzyme inhibitors (ACE-I) or angiotensin-II receptor blockers (ARB) in renal disease. Evidence in adult-onset SLE patients shows that these inhibitors of the renin-angiotensin system have a protective effect on the kidneys in case of proteinuria (29,30). Therefore, additional treatment with ACE-I and/or ARB in children with lupus nephritis and proteinuria should be advocated.…”

Recent advances in the treatment of lupus nephritis

“…The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative guidelines recommend interruption of the RAAS with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) as first-line anti-hypertensive therapy in the management of proteinuric kidney diseases, including lupus nephritis [9]. Both classes of drugs decrease intraglomerular pressure, lower systemic arterial blood pressure, reduce proteinuria, and delay the progression of lupus nephritis [10][11][12]. In a recent multiethnic US cohort study [11], 80 (21%) of 378 patients with lupus nephritis were treated with ACE inhibitors, and the rate of renal involvement-free survival at 10 years was 88.1% in the ACE inhibitor group and 75.4% in the non-ACE inhibitor group (P = 0.01).…”