Nonproteinuric Versus Proteinuric Phenotypes in Diabetic Kidney Disease: A Propensity Score–Matched Analysis of a Nationwide, Biopsy-Based Cohort Study

• DOI: 10.2337/dc18-1320
• Publication Date: 2019-04-23T02:45:31Z
• Authors: Masayuki Yamanouchi; Kengo Furuichi; Junichi Hoshino; Tadashi Toyama; Akinori Hara; Miho Shimizu; Keiichi Kinowaki; Takeshi Fujii; Kenichi Ohashi; Yukio Yuzawa; Hiroshi Kitamura; Yoshiki Suzuki; Hiroshi Sato; Noriko Uesugi; Satoshi Hisano; Yoshihiko Ueda; Shinichi Nishi; Hitoshi Yokoyama; Tomoya Nishino; Kenichi Samejima; Kentaro Kohagura; Yugo Shibagaki; Koki Mise; Hirofumi Makino; Seiichi Matsuo; Yoshifumi Ubara; Takashi Wada
• Keywords: Male; Biopsy; Middle Aged; Kidney; Kidney Function Tests; Prognosis; 3. Good health; Cohort Studies; 03 medical and health sciences; Phenotype; 0302 clinical medicine; Diabetes Mellitus, Type 2; Japan; Creatinine; Disease Progression; Albuminuria; Humans; Diabetic Nephropathies; Female; Prospective Studies; Propensity Score; Aged; Glomerular Filtration Rate

OBJECTIVE Clinicopathological characteristics, renal prognosis, and mortality in patients with type 2 diabetes and reduced renal function without overt proteinuria are scarce.

RESEARCH DESIGN AND METHODS We retrospectively assessed 526 patients with type 2 diabetes and reduced renal function (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2), who underwent clinical renal biopsy and had follow-up data, from Japan’s nationwide multicenter renal biopsy registry. For comparative analyses, we derived one-to-two cohorts of those without proteinuria versus those with proteinuria using propensity score–matching methods addressing the imbalances of age, sex, diabetes duration, and baseline eGFR. The primary end point was progression of chronic kidney disease (CKD) defined as new-onset end-stage renal disease, decrease of eGFR by ≥50%, or doubling of serum creatinine. The secondary end point was all-cause mortality.

RESULTS Eighty-two patients with nonproteinuria (urine albumin-to-creatinine ratio [UACR] <300 mg/g) had lower systolic blood pressure and less severe pathological lesions compared with 164 propensity score–matched patients with proteinuria (UACR ≥300 mg/g). After a median follow-up of 1.9 years (interquartile range 0.9–5.0 years) from the date of renal biopsy, the 5-year CKD progression-free survival was 86.6% (95% CI 72.5–93.8) for the nonproteinuric group and 30.3% (95% CI 22.4–38.6) for the proteinuric group (log-rank test P < 0.001). The lower renal risk was consistent across all subgroup analyses. The all-cause mortality was also lower in the nonproteinuric group (log-rank test P = 0.005).

CONCLUSIONS Patients with nonproteinuric diabetic kidney disease had better-controlled blood pressure and fewer typical morphological changes and were at lower risk of CKD progression and all-cause mortality.