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 >3 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 We compared the rate of GFR decline and incidence of ESRD in this cohort with 56 matched historical reference subjects who had received conventional therapy titrated to a target BP.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 -0.17 versus -0.56 ml/min per 1.73 m2; P < 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 with drawn 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.

Figure 1.

Algorithm describing the key steps of the Remission Clinic intervention protocol.

Figure 2.

Cumulative incidence of ESRD in 56 patients of the Remission Clinic receiving a multidrug treatment titrated to urinary proteins and 56 matched reference patients receiving a conventional treatment titrated to BP.

Figure 3.

SBP and DBP, serum cholesterol concentration, and 24-h urinary protein excretion rate throughout the whole study period in patients of the Remission Clinic receiving a multidrug treatment titrated to urinary proteins and matched reference patients receiving a conventional treatment titrated to BP. *P < 0.05, **P < 0.01, ***P < 0.001, ****P < 0.0001 (patients versus reference patients).

Figure 4.

SBP and DBP (top) and 24-h urinary protein excretion (bottom) at different time points after inclusion in the Remission Clinic in the three groups of patients with residual 24-h proteinuria ≥1, ≥0.3 and <1, or <0.3 g.

Figure 5.

Decline of eGFR after inclusion in the Remission Clinic in three groups of patients with residual 24-h proteinuria ≥1, ≥0.3 and <1, or <0.3 g. Data are means ± SEM.

Figure 6.

Decline of eGFR in the whole study group according to tertiles of achieved BP control and residual 24-h proteinuria.

Figure 7.

SBP and DBP (top) and 24-h urinary protein excretion (bottom) at different time points after inclusion in the Remission Clinic in patients with or without diabetes.

Figure 8.

SBP and DBP (top), 24-h urinary protein excretion (middle), and eGFR (bottom) at different time points before and after inclusion in the Remission Clinic in the 24 patients with at least three eGFR values available for slope analyses before inclusion.