Role of Remission Clinics in the Longitudinal Treatment of CKD

Abstract

Heavy proteinuria is a major determinant of progression to ESRD for patients with chronic nephropathies and reducing proteinuria should be a key target for renoprotective therapy. In the Remission Clinic, we applied a multimodal intervention to target urinary proteins in 56 consecutive patients who had Ͼ3 g proteinuria/d despite angiotensin-converting enzyme inhibitor therapy. We compared the rate of GFR decline and incidence of ESRD in this cohort with 56 matched historical reference subjects who had received conventional therapy titrated to a target BP. During a median follow-up of 4 yr, the monthly rate of GFR decline was significantly lower in the Remission Clinic cohort (median Ϫ0.17 versus Ϫ0.56 ml/min per 1.73 m 2 ; P Ͻ 0.0001), and ESRD events were significantly reduced (3.6 versus 30.4% reached ESRD). Follow-up BP, cholesterol, and proteinuria were lower in Remission Clinic patients than in reference subjects, such that disease remission or regression was achieved in up to 50% of patients who would have been otherwise expected to progress rapidly to ESRD on conventional therapy. Proteinuria reduction independently predicted a slower rate of GFR decline and ESRD incidence, but response to treatment differed depending on the underlying disease. Regarding safety, no patient was withdrawn because of hyperkalemia. In summary, multidrug treatment titrated to urinary protein level can be safely and effectively applied to normalize proteinuria and to slow the loss of renal function significantly, especially among patients without type 2 diabetes and with otherwise rapidly progressing chronic nephropathies.

Sodium Intake, ACE Inhibition, and Progression to ESRD

“…[1][2][3][4] These findings imply that urinary proteins should be reduced as far as possible, ideally to ,1 g/d. 5 Inhibitors of the renin-angiotensin system (RAS), such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), are the antihypertensive drugs that most effectively reduce urinary proteins and slow GFR decline in patients with CKD. 1-3, 6 The efficacy of treatment, however, is heterogeneous and dependent on inborn 7 and environmental [8][9][10][11][12] factors.…”

Blood Pressure, Proteinuria, and Phosphate as Risk Factors for Progressive Kidney Disease: A Hypothesis

“…This was demonstrated effectively by a multimodal intervention strategy, the Remission Clinic program, that used all available lifestyle recommendations and pharmacologic tools to further reduce proteinuria in patients with CKD and severe proteinuria already treated with RAAS-blocking agents. [46][47] We recently confirmed the beneficial effects of this strategy in patients with Alport syndrome. 48…”

Associação entre fatores de risco clínicos e laboratoriais e progressão da doença renal crônica pré-dialítica

“…[12][13][14] The prevalent CKD etiology was hypertensive nephrosclerosis (29%), followed by DKD (17%) and chronic glomerulonephritis (16%), which are related to the main causes of CKD in patients who underwent HD in Brazil. 3 Sesso et al and Fernandes et al showed that most patients who start on RRT in our country is referred to nephrology services very late, and most are on stage 4 (47.3%), which contrasts with data in international literature, in which most patients are on stage 3.…”

“…3 Sesso et al and Fernandes et al showed that most patients who start on RRT in our country is referred to nephrology services very late, and most are on stage 4 (47.3%), which contrasts with data in international literature, in which most patients are on stage 3. [3][4][5][6][7][8][9][10][11][12][13][14][15] Besides the expected contribution of age and CKD staging, the correlation of proteinuria with the progression of the renal disease, even if eased by the renoprotection by ACEI and ARB, is demonstrated in many studies. [16][17][18] This phenomenon is clearly observed in patients with type II DM, in which ¼ of the patients presents with renal compromise after ten years of disease.…”