Proteinuria lowering needs a multifactorial and individualized approach to halt progression of renal disease

This Practice Point commentary discusses the implementation of an intensive, multifactorial intervention in patients who had proteinuria >3g/day despite treatment with angiotensin-converting-enzyme inhibitors. In their 'Remission Clinic' in Bergamo, Italy, Ruggenenti et al. implemented an individual titration regimen using ramipril 5-10 mg/day, losartan 50-100 mg/day, verapamil 80-120 mg/day and atorvastatin 10-20 mg/day in successive steps, aiming for a low blood pressure target of <120/80 mmHg and a proteinuria target of <0.3 g/day. They found that patients treated in the Remission Clinic had a much slower decline in estimated glomerular filtration rate than a matched historical reference group treated with 1.25-5.00 mg ramipril (diastolic blood pressure goal <90 mmHg). Only 3.6% of Remission Clinic patients reached end-stage renal disease, compared with 30.4% of the historical controls. No information was provided on the individual responses to the different titration steps; therefore, the contributions of the specific components of the regimen towards the therapeutic benefit cannot be established. The data do, however, encourage an individualized and more active approach to preventing end-stage renal disease in individuals with proteinuric chronic kidney disease.