Alport syndrome: the effects of spironolactone on proteinuria and urinary TGF-β1

Alport syndrome (AS) is a progressive hereditary glomerular disease. Recent data indicate that aldosterone promotes fibrosis mediated by the transforming growth factor-beta 1 (TGF-beta 1) pathway, which may worsen proteinuria. Spironolactone (SP) antagonizes aldosterone and this study aimed to evaluate the efficacy of SP in reducing proteinuria and urinary TGF-beta 1 excretion in proteinuric AS patients. The study involved ten children with AS, normal renal function, and persistent proteinuria (> 6 months; uPr/uCr ratio > 1). SP 25 mg once a day for 6 months was added to existing ACE inhibitor treatment with or without angiotensin-II receptor blockade. Urine and blood samples were examined monthly. Urinary TGF-beta 1 levels were measured twice before and three times during SP treatment. Plasma renin activity (PRA) and serum aldosterone levels were also measured. In eight patients, uProt/uCreat was also assessed after 9 months and 12 months of SP treatment. After beginning SP therapy, all patients showed significant decrease in mean uProt/uCreat ratio (1.77 +/- 0.8 to 0.86 +/- 0.6; p < 0.001) and mean urinary TGF-beta 1 levels (104 +/- 54 to 41 +/- 20 pg/mgCreatinine; p < 0.01), beginning after 30 days of treatment and remaining stable throughout SP administration. PRA remain unchanged, and mean serum aldosterone increased from 105 +/- 72 pg/ml to 303 +/- 156 pg/ml (p < 0.001). The only side effect was gynecomastia in an obese boy. After 1 year of therapy, mean uProt/uCreat remains low (0.82 +/- 0.48). Addition of SP to ACE-I treatment with or without angiotensin II receptor blokers (ARB) significantly reduced proteinuria. This was mediated by decreased urinary TGF-beta 1 levels and not associated with major side effects.