Effect of a triple blockade of the renin-angiotensin-system in recurrent focal segmental glomerulosclerosis after kidney transplantation

Transpl Int. 2009 Nov;22(11):1110-3. doi: 10.1111/j.1432-2277.2009.00897.x. Epub 2009 May 20.

Abstract

Recurrent focal segmental glomerulosclerosis (FSGS) after renal transplantation with nephrotic syndrome is a serious problem with a high risk of graft loss. The therapeutic role of renin-angiotensin-system (RAS) blockers in recurrent FSGS is not clear. We present the safety and efficacy of an intensified triple RAS blockade with an ACE-inhibitor, an AT 1 receptor blocker and the direct renin inhibitor aliskiren in a 29-year-old renal transplant recipient with biopsy proven recurrence of FSGS and relapsing severe nephrotic syndrome. We subsequently used full dose ramipril, candesartan and aliskiren under a close monitoring of kidney function and electrolytes and examined the effect on proteinuria, clinical course and tolerability over 12 months. We found a significant and sustained antiproteinuric effect under triple RAS blockade. RAS blockade was generally well tolerated. This can offer a new therapeutic approach in selected hypertensive patients with recurrent FSGS.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Amides / administration & dosage
  • Amides / therapeutic use*
  • Angiotensin II Type 1 Receptor Blockers / administration & dosage
  • Angiotensin II Type 1 Receptor Blockers / therapeutic use*
  • Angiotensin-Converting Enzyme Inhibitors / administration & dosage
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Antibodies, Monoclonal / therapeutic use
  • Antibodies, Monoclonal, Murine-Derived
  • Benzimidazoles / administration & dosage
  • Benzimidazoles / therapeutic use*
  • Biphenyl Compounds
  • Drug Therapy, Combination
  • Female
  • Fumarates / administration & dosage
  • Fumarates / therapeutic use*
  • Glomerulosclerosis, Focal Segmental / complications
  • Glomerulosclerosis, Focal Segmental / drug therapy*
  • Glomerulosclerosis, Focal Segmental / pathology
  • Glomerulosclerosis, Focal Segmental / surgery
  • Humans
  • Hypertension, Renal / drug therapy*
  • Hypertension, Renal / etiology
  • Kidney Transplantation*
  • Nephrotic Syndrome / drug therapy
  • Nephrotic Syndrome / etiology
  • Plasma Exchange
  • Proteinuria / drug therapy
  • Proteinuria / etiology
  • Ramipril / administration & dosage
  • Ramipril / therapeutic use*
  • Recurrence
  • Renin / antagonists & inhibitors*
  • Renin-Angiotensin System / drug effects*
  • Rituximab
  • Tetrazoles / administration & dosage
  • Tetrazoles / therapeutic use*

Substances

  • Amides
  • Angiotensin II Type 1 Receptor Blockers
  • Angiotensin-Converting Enzyme Inhibitors
  • Antibodies, Monoclonal
  • Antibodies, Monoclonal, Murine-Derived
  • Benzimidazoles
  • Biphenyl Compounds
  • Fumarates
  • Tetrazoles
  • Rituximab
  • aliskiren
  • Renin
  • Ramipril
  • candesartan