UKidney Nephrology News and Insights

Estimates of glomerular filtration rate (GFR) have been the mainstay of kidney functional assessment for some time and have been the most widely relied upon test to predict progression to end-stage renal disease (ESRD). Urinary microalbuminuria (MAU) has more recently been added to the assessment of chronic kidney disease. In this month's issue of the Journal of the American Society of Nephrology, researches confirm that the use of these two tests in conjunction improves the accuracy of predicting which patients will go on to develop ESRD. According to their analysis, if one uses eGFR and MAU together, the number of patients referred to a nephrologist that ultimately develop ESRD would fall from 38.4 to 11.4. This dramatic reduction implies that these 2 tests when used in conjunction greatly increases the diagnostic and prognostic accuracy of primary care physicians assessing for chronic kidney disease.

For  a presentation on this topic, please see these links on UKidney:

1. Microalbuminuria testing
2. eGFR and MAU in primary care

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In the wake of the ONTARGET study, there is a movement away from using ACE and ARBs in combination for hypertension or general vascular protection. However, the combination is still an option for patients with heart failure where the it has been shown to reduce hospitalization. There remains a question whether the combination can reduce the rate of progression in diabetic nephropathy and other kidney diseases. While the ONTARGET study did include a relatetively small number of patients with nephropathy, it was not designed or powered to show a difference in renal outcomes. A new study, the VA-NEPHRON D, is currently underway to examine the effect of lisinopril plus losartan versus lisinopril plus placebo on the progression of chronic kidney disease. A copy of this study design can be found here. This study should shed light on the role of this medication combination in a disease state with a large unmet therapeutic need.

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After disappointing findings in the 4D Study, a subsequent trial reported in a recent issue of the New England Journal of Medicine once again demonstrated disappointing results with statin therapy in patients with end-stage renal failure. In the AURORA study, 2776 patients aged 50-80 were randomized to 10 mg of Crestor or placebo. Despite an average of 43% reduction in LDL, there was no change in the primary end-point of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke after 3.8 years of follow-up.

This study is an unfortunate reminder of the difficulty creating measurable impact on hard clinical end-points in patients with end-stage renal failure.

 

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