One third of patients with type 1 diabetes and microalbuminuria experience an early, progressive decline in renal function that leads to advanced stages of chronic kidney disease and ESRD. We hypothesized that the urinary proteome may distinguish between stable renal function and early renal function decline among patients with type 1 diabetes and microalbuminuria. We followed patients with normal renal function and microalbuminuria for 10 to 12 yr and classified them into case patients (n ϭ 21) with progressive early renal function decline and control subjects (n ϭ 40) with stable renal function. Using liquid chromatography matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, we identified three peptides that decreased in the urine of patients with early renal function decline [fragments of ␣1(IV) and ␣1(V) collagens and tenascin-X] and three peptides that increased (fragments of inositol pentakisphosphate 2-kinase, zona occludens 3, and FAT tumor suppressor 2). In renal biopsies from patients with early nephropathy from type 1 diabetes, we observed increased expression of inositol pentakisphosphate 2-kinase, which was present in granule-like cytoplasmic structures, and zona occludens 3. These results indicate that urinary peptide fragments reflect changes in expression of intact protein in the kidney, suggesting new potential mediators of diabetic nephropathy and candidate biomarkers for progressive renal function decline. 20: 206520: -207420: , 200920: . doi: 10.1681 Microalbuminuria (MA) has been the primary diagnostic test to identify patients who have type 1 diabetes and are at risk for overt proteinuria and subsequent declining renal function leading to ESRD 1,2 ; however, the predictive value of MA is now questioned. First, a large proportion of patients with MA can revert to normoalbuminuria 3-5 ; second, only a minority of patients with MA progress to proteinuria 3,6 ; and, third, in one third of patients with MA, progressive renal function decline starts already at the onset of MA, not proteinuria. The last process we refer to as early renal function decline (ERFD). 7 Our understanding of the disease process underlying ERFD is limited. The existing hypotheses about the cause of diabetic nephropathy (DN) are in question given that progressive ERFD is initiated
J Am Soc Nephrol