Skip to main content
SpringerLink
Log in

Successful effect of triple blockade of renin–angiotensin–aldosterone system on massive proteinuria in a patient with chronic kidney disease

  • Case Report
  • Published:
Clinical and Experimental Nephrology Aims and scope Submit manuscript

Abstract

A patient with chronic kidney disease (CKD) due to membranous nephropathy with daily urinary protein excretion exceeding 5 g did not respond well to dual therapy with an angiotensin converting enzyme inhibitor (ACE-I) and angiotensin II receptor blocker (ARB). Addition of the mineralocorticoid receptor blocker (MRB), spironolactone, led to moderate reduction in daily urinary protein excretion. However, spironolactone had to be inevitably discontinued due to gynecomastia. Replacement of spironolactone with the selective MRB, eplerenone, added to the preceding treatment with ACE-I and ARB, resulted in remarkable reduction of daily urinary protein excretion to less than 0.2 g. This case suggests that triple blockade of renin–angiotensin–aldosterone (RAA) system with ACE-I, ARB, and MRB could be useful for CKD patients with massive proteinuria.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Russo D, Minutolo R, Pisani A, Esposito R, Signoriello G, Andreucci M, et al. Coadministration of losartan and enalapril exerts additive antiproteinuric effect in IgA nephropathy. Am J Kidney Dis. 2001;38:18–25.

    Article  CAS  PubMed  Google Scholar 

  2. Russo D, Pisani A, Belletta MM, De Nicola L, Savino FA, Andreucci M, et al. Additive antiproteinuric effect of converting enzyme inhibitor and losartan in normotensive patients with IgA nephropathy. Am J Kidney Dis. 1999;33:851–6.

    Article  CAS  PubMed  Google Scholar 

  3. Kuriyama S, Tomonari H, Abe A, Imasawa T, Hosoya T. Beneficial effect of combination therapy with angiotensin II receptor antagonist and angiotensin converting enzyme inhibitor on overt proteinuria in a patient with type I diabetic nephropathy. Nephron. 2000;86:529–30.

    Article  CAS  PubMed  Google Scholar 

  4. Mogensen CE, Neldam S, Tikkanen I, Oren S, Viskoper R, Watts RW, et al. Randomized controlled trial of dual blockade of renin angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study. Brit Med J. 2000;321:1440–4.

    Article  CAS  Google Scholar 

  5. Nakao N, Yoshimura A, Morita H, Takada M, Kayano T, Ideura T. Combination treatment of angiotensin II receptor blocker and angiotensin converting enzyme inhibitor in non-diabetic renal disease COOPERATE: a randomized controlled trial. Lancet. 2003;361:117–24.

    Article  CAS  PubMed  Google Scholar 

  6. Mann JF, Schmieder RE, McQueen M, Dyal L, Schumacher H, Pogue J, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomized, double-blind, controlled trial. Lancet. 2008;372:547–53.

    Article  CAS  PubMed  Google Scholar 

  7. Takeda Y, Yoneda T, Demura M, Furukawa K, Miyamori I, Mabuchi H. Effects of sodium intake on cardiovascular aldosterone synthesis in stroke-prone spontaneously hypertensive rats. J Hypertens. 2001;19:635–9.

    Article  CAS  PubMed  Google Scholar 

  8. Nagase M, Matsui H, Shibata S, Gotoda T, Fujita T. Salt-induced nephropathy in obese spontaneously hypertensive rats via paradoxical activation of the mineralocorticoid receptor: Role of oxidative stress. Hypertension. 2007;50:877–83.

    Article  CAS  PubMed  Google Scholar 

  9. Bianchi S, Bigazzi R, Campese VM. Long-term effect of spironolactone on proteinuria and kidney function in patients with chronic kidney disease. Kidney Int. 2006;70:2116–23.

    Article  CAS  PubMed  Google Scholar 

  10. Schjoedt KJ, Rossing K, Juhl TR, Boomsma F, Tarnow L, Rossing P, et al. Beneficial impact of spironolactone in diabetic nephropathy. Kidney Int. 2005;68:2829–36.

    Article  CAS  PubMed  Google Scholar 

  11. Furumatsu Y, Nagasawa Y, Tomida K, Mikami S, Kaneko T, Okada N, et al. Effect of renin angiotensin aldosterone system triple blockade on non-diabetic renal disease: Addition of an aldosterone blocker, spironolactone, to combination treatment with an angiotensin converting enzyme inhibitor with an angiotensin II receptor blocker. Hypertens Res. 2008;31:59–67.

    Article  CAS  PubMed  Google Scholar 

  12. Tylicki L, Rutkowski P, Renke M, Larcznski W, Aleksandrowicz E, Lysiak-Szydlowska W, et al. Triple pharmacological blockade of the renin angiotensin aldosterone system in non-diabetic CKD: An open-label crossover randomized controlled trial. Am J Kidney Dis. 2008;52:486–93.

    Article  CAS  PubMed  Google Scholar 

  13. Rogerson F, Yao Y, Smith BJ, Fuller PJ. Differences in the determinants of eplerenone, spironolactone and aldosterone binding to the mineralocorticoid receptor. Clin Exp Pharmacol Physiol. 2004;31:704–9.

    Article  CAS  PubMed  Google Scholar 

  14. Garthwaite SM, McMahon EG. The evolution of aldosterone antagonists. Mol Cell Endocrinol. 2004;217:27–31.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

There were no grants or funds in support of the study.

Conflict of interest statement

There was no conflict of interest.

Author information

Authors and Affiliations

  1. Division of Nephrology, Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo, 108-0073, Japan

    Satoru Kuriyama, Naoki Sugano, Hiroyuki Ueda, Yasushi Otsuka & Go Kanzaki

  2. Department of Kidney and Hypertension, Jikei University, Tokyo, Japan

    Tatsuo Hosoya

Authors
  1. Satoru Kuriyama
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Naoki Sugano
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hiroyuki Ueda
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yasushi Otsuka
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Go Kanzaki
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Tatsuo Hosoya
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Satoru Kuriyama.

About this article

Cite this article

Kuriyama, S., Sugano, N., Ueda, H. et al. Successful effect of triple blockade of renin–angiotensin–aldosterone system on massive proteinuria in a patient with chronic kidney disease. Clin Exp Nephrol 13, 663–666 (2009). https://doi.org/10.1007/s10157-009-0213-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10157-009-0213-3

Keywords

Search

Navigation