Remission of membranoproliferative nephritis with angiotensin converting enzyme inhibition and receptor blockade

Abstract

The conventional therapy for children with heavy proteinuria due to idiopathic membranoproliferative glomerulonephritis (MPGN) has involved the use of immunosuppressive medications, most commonly corticosteroids [1, 2]. The renoprotection afforded by the angiotensin converting enzyme (ACE) inhibitors and by angiotensinII receptor blockers (ARB) has resulted in an increased use of these agents in many glomerular diseases, especially in combination [3]. We report our experience in managing a 14-year-old girl with hematuria, nephroticrange proteinuria (15 g/day), and a low serum albumin (2.5 g/dl), who on biopsy was found to have idiopathic type I MPGN (negative hepatitis B and C serology and a negative antinuclear antibody). Since she was clinically asymptomatic, with normal blood pressure, normal renal function (serum creatinine 0.5 mg/dl, corresponding to a calculated creatinine clearance of 173 ml/min per 1.73 m2), and no edema, we elected to withhold corticosteroids. Since she remained proteinuric and hypoalbuminemic over a 3-month observation period, she was started on an ACE inhibitor with gradual dose escalation (lisinopril 5 mg/day increased to 10 mg/day). Three months later an ARB (valsartan 80 mg/day) was added since she was persistently proteinuric (urine protein excretion of 15 g/day) and hypoalbuminemic (2.5 g/dl). Within 2 months of adding the ARB, her proteinuria decreased to 2 g/day and her serum albumin increased to 3.2 g/dl. At last follow-up, 16 months after diagnosis, our patient is in complete remission; her serum albumin is normal (3.8 g/dl) and she has only 200 mg/day of urinary protein. Her renal function (serum creatinine 0.6 mg/dl) and blood pressure (107/53 mmHg) continue to be normal, and she has not developed any adverse effects attributable to her medications. A repeat renal biopsy obtained a year after the initial biopsy showed no evidence of chronic renal damage (interstitial fibrosis), although the disease activity was unchanged. We feel that this case highlights the efficacy of ACE inhibitors and ARB in reducing proteinuria in glomerular diseases. These agents, which have traditionally not been considered immunosuppressive, certainly do have immunomodulating effects [4] and may provide a safer alternative to the more conventional, albeit more toxic, medications such as corticosteroids.

DOI: 10.1007/s00467-003-1296-9

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@article{Butani2003RemissionOM, title={Remission of membranoproliferative nephritis with angiotensin converting enzyme inhibition and receptor blockade}, author={Lavjay Butani}, journal={Pediatric Nephrology}, year={2003}, volume={18}, pages={1199-1199} }