An Outcomes-Based Definition of Proteinuria Remission in Focal Segmental Glomerulosclerosis

Author:

Troost Jonathan P.,Trachtman Howard,Nachman Patrick H.,Kretzler Matthias,Spino Cathie,Komers Radko,Tuller Sarah,Perumal Kalyani,Massengill Susan F.,Kamil Elaine S.,Oh Gia,Selewski David T.,Gipson Patrick,Gipson Debbie S.ORCID

Abstract

Background and objectivesProteinuria is used as an indicator of FSGS disease activity, but its use as a clinical trial end point is not universally accepted. The goal of this study was to refine proteinuria definitions associated with long-term kidney survival.Design, setting, participants, & measurementsData on 466 patients with primary FSGS with proteinuria (urine protein-to-creatinine ratio >1 g/g) were analyzed from five independent cohorts. Proteinuria by months 1, 4, and 8 after study baseline was categorized by conventional definitions of complete (<0.3 g/g) and partial remission (<3.5 g/g and 50% reduction in proteinuria). Novel remission definitions were explored using receiver operating curves. Kaplan–Meier methods were used to estimate the associations of proteinuria with progression to ESRD or a 50% loss in kidney function. Propensity score–adjusted Cox proportional hazards models were used to adjust for baseline proteinuria, eGFR, and therapy.ResultsIn the initial derivation cohort, conventional partial remission was not associated with kidney survival. A novel definition of partial remission (40% proteinuria reduction and proteinuria<1.5 g/g) on the basis of receiver operating curve analyses of 89 patients was identified (Sensitivity=0.70; Specificity=0.77). In the validation cohort analyses, complete remission was associated with better prognosis (6 out of 41 patients progressed to kidney failure; 6.6 per 100 patient-years) as was the novel partial remission (13 out of 71 progressed; 8.5 per 100 patient-years), compared with those with no response (51 out of 116 progressed; 20.1 per 100 patient-years). Conventional partial remission at month 8, but not month 4, was also associated with better response (19 out of 85 patients progressed; risk=10.4 per 100 patient-years). Propensity score–adjusted analyses showed the novel partial remission was associated with less progression at months 4 and 8 (month 4: hazard ratio, 0.50; P=0.01; month 8: hazard ratio, 0.30; P=0.002).ConclusionsReaching either a complete or partial remission using a novel or conventional definition was associated with better long-term outcomes in patients with FSGS.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_02_20_CJASNPodcast_18_3_T.mp3

Publisher

American Society of Nephrology (ASN)

Subject

Transplantation,Nephrology,Critical Care and Intensive Care Medicine,Epidemiology

Reference17 articles.

1. United States Renal Data System : 2015 USRDS Annual Data Report: Epidemiology of Kidney isease in the United States, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2015

2. Notice

3. Recent advances in treatments of primary focal segmental glomerulosclerosis in children.;Han;BioMed Res Int

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5. Trachtman H : Efficacy and safety of RE-021, a dual endothelin receptor and angiotensin receptor blocker, in patients with focal segmental glomerulosclerosis (FSGS): A randomized, double-blind, active-control, dose-escalation study (2012). Available at https://clinicaltrials.gov/ct2/show/NCT01613118. Accessed April 17, 2017

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