Effect of renin-angiotensin-aldosterone system inhibition, dietary sodium restriction, and/or diuretics on urinary kidney injury molecule 1 excretion in nondiabetic proteinuric kidney disease: a post hoc analysis of a randomized controlled trial

Am J Kidney Dis. 2009 Jan;53(1):16-25. doi: 10.1053/j.ajkd.2008.07.021. Epub 2008 Sep 27.


Background: Tubulointerstitial damage plays an important role in chronic kidney disease (CKD) with proteinuria. Urinary kidney injury molecule 1 (KIM-1) reflects tubular KIM-1 and is considered a sensitive biomarker for early tubular damage. We hypothesized that a decrease in proteinuria by using therapeutic interventions is associated with decreased urinary KIM-1 levels.

Study design: Post hoc analysis of a randomized, double-blind, placebo-controlled, crossover trial.

Setting & participants: 34 proteinuric patients without diabetes from our outpatient renal clinic.

Intervention: Stepwise 6-week interventions of losartan, sodium restriction (low-sodium [LS] diet), their combination, losartan plus hydrochlorothiazide (HCT), and the latter plus an LS diet.

Outcomes & measurements: Urinary excretion of KIM-1, total protein, and N-acetyl-beta-d-glucosaminidase (NAG) as a positive control for tubular injury.

Results: Mean baseline urine protein level was 3.8 +/- 0.4 (SE) g/d, and KIM-1 level was 1,706 +/- 498 ng/d (increased compared with healthy controls; 74 ng/d). KIM-1 level was decreased by using placebo/LS (1,201 +/- 388 ng/d; P = 0.04), losartan/high sodium (1,184 +/- 296 ng/d; P = 0.09), losartan/LS (921 +/- 176 ng/d; P = 0.008), losartan/high sodium plus HCT (862 +/- 151 ng/d; P = 0.008) and losartan/LS plus HCT (743 +/- 170 ng/d; P = 0.001). The decrease in urinary KIM-1 levels paralleled the decrease in proteinuria (R = 0.523; P < 0.001), but not blood pressure or creatinine clearance. 16 patients reached target proteinuria with protein less than 1 g/d, whereas KIM-1 levels normalized in only 2 patients. Urinary NAG level was increased at baseline and significantly decreased during the treatment periods of combined losartan plus HCT only. The decrease in urinary NAG levels was not closely related to proteinuria.

Limitations: Post hoc analysis.

Conclusions: Urinary KIM-1 level was increased in patients with nondiabetic CKD with proteinuria and decreased in parallel with proteinuria by using losartan, sodium restriction, their combination, losartan plus HCT, and the latter plus sodium restriction. These results are consistent with the hypothesis of amelioration of proteinuria-induced tubular damage. Long-term studies are warranted to evaluate whether targeting treatment on KIM-1 can improve outcomes in patients with CKD with proteinuria.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Acetylglucosaminidase / urine
  • Adult
  • Aged
  • Antihypertensive Agents / therapeutic use
  • Biomarkers / urine
  • Chronic Disease
  • Combined Modality Therapy
  • Cross-Over Studies
  • Diuretics / pharmacology
  • Diuretics / therapeutic use*
  • Double-Blind Method
  • Drug Therapy, Combination
  • Female
  • Hepatitis A Virus Cellular Receptor 1
  • Humans
  • Hydrochlorothiazide / therapeutic use
  • Kidney Diseases / drug therapy
  • Kidney Diseases / physiopathology
  • Kidney Diseases / urine*
  • Losartan / therapeutic use
  • Male
  • Membrane Glycoproteins / urine*
  • Middle Aged
  • Proteinuria / drug therapy
  • Proteinuria / physiopathology
  • Proteinuria / urine*
  • Receptors, Virus
  • Renin-Angiotensin System / drug effects
  • Renin-Angiotensin System / physiology*
  • Sodium, Dietary / pharmacology
  • Sodium, Dietary / therapeutic use*
  • Treatment Outcome


  • Antihypertensive Agents
  • Biomarkers
  • Diuretics
  • HAVCR1 protein, human
  • Hepatitis A Virus Cellular Receptor 1
  • Membrane Glycoproteins
  • Receptors, Virus
  • Sodium, Dietary
  • Hydrochlorothiazide
  • Acetylglucosaminidase
  • Losartan