Tacrolimus decreases albuminuria in patients with IgA nephropathy and normal blood pressure: a double-blind randomized controlled trial of efficacy of tacrolimus on IgA nephropathy
Yong-Chul Kim, Ho Jun Chin, Ho Suk Koo, Suhnggwon Kim, Yong-Chul Kim, Ho Jun Chin, Ho Suk Koo, Suhnggwon Kim
Abstract
Background: Treatment remains uncertain for IgA nephropathy patients with mild to moderate proteinuria, for whom anti-hypertensive medication or the RAS blocker is not applicable due to low blood pressure.
Trial design: A double blinded randomized trial.
Methods: The anti-proteinuric effect of tacrolimus was explored for 40 biopsy-proven mild IgA nephropathies for 16 weeks. We randomly assigned patients either to receive tacrolimus or placebo with stratification by using a renin angiotensin system blocker. The primary outcome was the percentage change of final UACR compared to the baseline value (pcUACR).
Results: The mean value of pcUACR at 12-week and 16-week visits (primary outcome) was decreased more in the Tac group compared to the control group (-52.0±26.4 vs -17.3±29.3%, p = 0.001). At each visit, pcUACR was also decreased more in the Tac group compared to the control group. In the Tac group, the pcUACRs were -60.2±28.2%, -62.2±33.9%, -48.5±29.8%, and -55.5±24.0%, and, in the control group, -6.8±32.2%, -2.5±35.9%, -12.7±34.2%, and -21.9±30.6%, at 4-week, 8-week, 12-week, and 16-week visits, respectively. The pre-defined secondary outcomes were better in the Tac group compared to the control group. The frequency of decrease in pcUACR and percentage change of UPCR (pcUPCR) ≥50% at 16 weeks were 65.0% (13/20) and 55.0% (11/20)in the Tac group, and 25.0% (5/20) and 15.0% (3/20), in the control group, respectively (p = 0.025 for pcUACR and p = 0.019 for pcUPCR). However, tacrolimus wasn't effective with a dose of 0.05 mg/kg/day in patients taking ARB. The adverse events were tolerable.
Conclusion: Tacrolimus effectively reduced proteinuria in IgA nephropathy with normal blood pressure. This suggested that tacrolimus could be an alternative to corticosteroid and RAS blocker for IgA nephropathy patients who cannot endure anti-hypertensive medication.
Trial registration: Clinicaltrial.gov NCT1224028.
Trial registration: ClinicalTrials.gov NCT01224028 NCT01224028.
Conflict of interest statement
Competing Interests: This study was supported by Astellas pharma Korea. HJC and SK had another research grant from Astellas pharma Korea and have been conducting a clinical trial. Astellas pharma Korea owns the branded version of the drug being investigated in this study. There are no further patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.
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References
- Chang JH, Kim DK, Kim HW, Park SY, Yoo TH, et al. (2009) Changing prevalence of glomerular diseases in Korean adults: a review of 20 years of experience. Nephrol Dial Transplant 24(8): 2406–2410.
- Lee H, Kim DK, Oh KH, Joo KW, Kim YS, et al. (2013) Mortality and renal outcome of primary glomerulonephritis in Korea: Observation in 1,943 biopsied cases. Am J Nephrol 37(1): 74–83.
- D'Amico G (1987) The commonest glomerulonephritis in the world: IgA nephropathy. Q J Med 64(245): 709–727.
- Geddes CC, Rauta V, Gronhagen-Riska C, Bartosik LP, Jardine AG, et al. (2003) A tricontinental view of IgA nephropathy. Nephrol Dial Transplant 18(8): 1541–1548.
- Floege J, Eitner F (2011) Current therapy for IgA nephropathy. J Am Soc Nephrol 22(10): 1785–1794.
- Koyama A, Igarashi M, Kobayashi M (1997) Natural history and risk factors for immunoglobulin A nephropathy in Japan. Research Group on Progressive Renal Diseases. Am J Kidney Dis 29(4): 526–532.
- Berthoux F, Mohey H, Laurent B, Mariat C, Afiani A, et al. (2011) Predicting the risk for dialysis or death in IgA nephropathy. J Am Soc Nephrol 22(4): 752–761.
- Li PK, Ho KK, Szeto CC, Yu L, Lai FM (2002) Prognostic indicators of IgA nephropathy in the Chinese–clinical and pathological perspectives. Nephrol Dial Transplant 17(1): 64–69.
- Lee H, Kim DK, Oh KH, Joo KW, Kim YS, et al. (2012) Mortality of IgA Nephropathy Patients. A Single Center Experience over 30 Years. PLoS One 7(12): e51225.
- Radford MG Jr, Donadio JV Jr, Bergstralh EJ, Grande JP (1997) Predicting renal outcome in IgA nephropathy. J Am Soc Nephrol 8(2): 199–207.
- Neelakantappa K, Gallo GR, Baldwin DS (1988) Proteinuria in IgA nephropathy. Kidney Int 33(3): 716–721.
- Usui J, Yamagata K, Kai H, Outeki T, Yamamoto S, et al. (2001) Heterogeneity of prognosis in adult IgA nephropathy, especially with mild proteinuria or mild histological features. Intern Med 40(8): 697–702.
- Shen P, He L, Huang D (2008) Clinical course and prognostic factors of clinical early IgA nephropathy. Neth J Med 66(6): 242–247.
- Szeto CC, Lai FM, To KF, Wong TY, Chow KM, et al. (2001) The natural history of immunoglobulin a nephropathy among patients with hematuria and minimal proteinuria. Am J Med 110(6): 434–437.
- TESTING Study Group; Lv J, Xu D, Perkovic V, Ma X, Johnson DW, et al (2012) Corticosteroid therapy in IgA nephropathy. J Am Soc Nephrol 23(6): 1108–1116.
- Zhou YH, Tang LG, Guo SL, Jin ZC, Wu MJ, et al. (2011) Steroids in the treatment of IgA nephropathy to the improvement of renal survival: a systematic review and meta-analysis. PLoS One 6(4): e18788.
- Zhang Q, Shi SF, Zhu L, Lv JC, Liu LJ, et al. (2012) Tacrolimus improves the proteinuria remission in patients with refractory IgA nephropathy. Am J Nephrol 35(4): 312–320.
- Faul C, Donnelly M, Merscher-Gomez S, Chang YH, Franz S, et al. (2008) The actin cytoskeleton of kidney podocytes is a direct target of the antiproteinuric effect of cyclosporine A. Nat Med. 14(9): 931–938.
- CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration); Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, et al (2009) A new equation to estimate glomerular filtration rate. Ann Intern Med 150(9): 604–612.
- Nakamura T, Inoue T, Sugaya T, Kawagoe Y, Suzuki T, et al. (2007) Beneficial effects of olmesartan and temocapril on urinary liver-type fatty acid-binding protein levels in normotensive patients with immunoglobin A nephropathy. Am J Hypertens 20(11): 1195–1201.
- Shimizu A, Takei T, Uchida K, Tsuchiya K, Nitta K (2008) Low-dose losartan therapy reduces proteinuria in normotensive patients with immunoglobulin A nephropathy. Hypertens Res 31(9): 1711–1717.
- Tomino Y, Kawamura T, Kimura K, Endoh M, Hosoya T, et al. (2009) Antiproteinuric effect of olmesartan in patients with IgA nephropathy. J Nephrol 22(2): 224–231.
- Ferraro PM, Ferraccioli GF, Gambaro G, Fulignati P, Costanzi S (2009) Combined treatment with renin-angiotensin system blockers and polyunsaturated fatty acids in proteinuric IgA nephropathy: a randomized controlled trial. Nephrol Dial Transplant 24(1): 156–160.
- Horita Y, Tadokoro M, Taura K, Ashida R, Hiu M, et al. (2007) Prednisolone co-administered with losartan confers renoprotection in patients with IgA nephropathy. Ren Fail 29(4): 441–446.
- Working Group of the International IgA Nephropathy Network and the Renal Pathology Society; Cattran DC, Coppo R, Cook HT, Feehally J, Roberts IS, et al (2009) The Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and classification. Kidney Int 76(5): 534–545.
- Grupo de Estudio de Enfermedades Glomerulares de la Sociedad Española de Nefrología (GLOSEN); Gutiérrez E, Zamora I, Ballarín JA, Arce Y, Jiménez S, et al (2001) Long-term outcomes of IgA nephropathy presenting with minimal or no proteinuria. J Am Soc Nephrol 23(10): 1753–1760.
- Toronto Glomerulonephritis Registry; Reich HN, Troyanov S, Scholey JW, Cattran DC (2007) Remission of proteinuria improves prognosis in IgA nephropathy. J Am Soc Nephrol 18(12): 3177–3183.
- Fan L, Liu Q, Liao Y, Li Z, Ji Y, et al... (2012) Tacrolimus is an alternative therapy option for the treatment of adult steroid-resistant nephrotic syndrome: a prospective, multicenter clinical trial. Int Urol Nephrol [Epub ahead of print].
- Arikan H, Koc M, Cakalagaoglu F, Eren Z, Segal MS, et al. (2008) Tacrolimus rescue therapy in resistant or relapsing cases of primary glomerulonephritis. J Nephrol 21(5): 713–721.
- Li X, Li H, Chen J, He Q, Lv R, et al. (2008) Tacrolimus as a steroid-sparing agent for adults with steroid-dependent minimal change nephrotic syndrome. Nephrol Dial Transplant 23(6): 1919–1925.
- Chen W, Liu Q, Liao Y, Yang Z, Chen J, et al. (2013) Outcomes of Tacrolimus Therapy in Adults With Refractory Membranous Nephrotic Syndrome: A Prospective, Multicenter Clinical Trial. Am J Med Sci 345(2): 81–87.
- Uchino A, Tsukamoto H, Nakashima H, Yoshizawa S, Furugo I, et al. (2010) Tacrolimus is effective for lupus nephritis patients with persistent proteinuria. Clin Exp Rheumatol 28(1): 6–12.
- Lee T, Oh KH, Joo KW, Kim YS, Ahn C, et al. (2010) Tacrolimus is an alternative therapeutic option for the treatment of refractory lupus nephritis. Lupus 19(8): 974–980.
- Boots JM, van Duijnhoven EM, Christiaans MH, Nieman FH, van Suylen RJ, et al. (2001) Single-center experience with tacrolimus versus cyclosporine-Neoral in renal transplant recipients. Transpl Int 14(6): 370–383.
- Textor SC, Burnett JC Jr, Romero JC, Canzanello VJ, Taler SJ, et al. (1995) Urinary endothelin and renal vasoconstriction with cyclosporine or FK506 after liver transplantation. Kidney Int 47(5): 1426–1433.
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