résumés des cours et travaux - Collège de France

RÉSUMÉS DES COURS ET CONFÉRENCES 931
therapy, giving rise to the feeling that these agents have beneficial effects above and
beyond what can be achieved with blood pressure control alone.
At present, there is a balancing act between the control of blood pressure and
control of proteinuria. Even in the most well defined outcome studies of type I,
and type II diabetes, the outcomes with respect to slowing the rate of progression
of CKD, though significant, do not achieve the ultimate goal of reducing the
progression rate to < 1 ml/min/1.73 m 2 /year.
A new paradigm is emerging that focuses directly on the control of proteinuria to
less than 0.5 grams/day with ACEI/ARB therapy and also other non-traditional
forms of therapy including other forms of RAS blockers, vitamin D, and other
agents.
These issues will be put in focus for the case of Fabry nephropathy. Fabry disease
is a rate multi-system disease caused by a mutation in the alpha-galactosidase A
gene on the X-chromosome. It is a progressive form of proteinuric CKD, but in
contrast to diabetes, the systolic blood pressure is not usually elevated, which
makes the utilization of traditional anti-proteinuric therapy challenging.
In conclusion, the importance of control of proteinuria in slowing the progression
of CKD will be emphasized with the use of a combination of treatment approaches
to achieve this goal. In this context, control of proteinuria, per se, rather than
lowering the systolic blood pressure to an arbitrary, fixed goal becomes the primary
outcome measure. While this approach clearly has merit, long-term outcome
studies are need before reduction of urinary protein excretion can be accepted as
a surrogate endpoint for slowing the progression of CKD.