original article
org
see commentary on page 2051
Long-term effects of spironolactone on proteinuria
and kidney function in patients with chronic kidney
disease
S Bianchi1, R Bigazzi1 and VM Campese2
1
Unita` Operativa Nefrologia, Spedali Riuniti, Livorno, Italy and 2Division of Nephrology, Keck School of Medicine, USC, Los Angeles,
California, USA
Experimental evidence suggests that aldosterone contributes
to progressive kidney disease. Angiotensin-converting
enzyme inhibitors and angiotensin type 1 receptor
antagonists suppress the reninangiotensin system but
they do not effectively reduce plasma aldosterone. Hence,
administration of aldosterone receptor antagonists may
provide additional renal protection. In the present
prospective randomized open-label study, we evaluated
the effects of spironolactone (25 mg/day for 1 year) on
proteinuria and estimated glomerular filtration rate in
83 patients with chronic kidney disease already treated
with angiotensin-converting enzyme inhibitors and/or
angiotensin type 1 receptor antagonists. Eighty-two patients
were treated with angiotensin-converting enzyme inhibitors
and/or angiotensin type 1 receptor antagonists alone and
served as controls. After 1 year of therapy, proteinuria
decreased from 2.170.08 to 0.8970.06 g/g creatinine
(Po0.001) in patients treated with spironolactone, but it did
not change in control patients. Baseline aldosterone levels
were significantly correlated with proteinuria (r 0.76,
Po0.0001), and predicted the degree of reduction in
proteinuria with spironolactone (r 0.42, Po0.0002).
Baseline estimated glomerular filtration rate was similar in
patients treated with spironolactone and controls (62.472.4
and 62.272.1 ml/min/1.73 m2, respectively). After 1 month of
therapy with spironolactone, estimated glomerular filtration
rate decreased more in patients treated with spironolactone
than in controls. However, by the end of 1 year the monthly
rate of decrease in estimated glomerular filtration rate from
baseline was lower in patients treated with spironolactone
than in controls (0.32370.044 vs 0.47470.037 ml/min/
1.73 m2, Po0.01). Spironolactone caused a significant rise
in serum potassium levels (from 4.270.04 at baseline to
5.070.05 mEq/l after 12 months of treatment, Po0.001). In
conclusion, this study has shown that spironolactone may
reduce proteinuria and retard renal progression in chronic
kidney disease patients.
Correspondence: VM Campese, Keck School of Medicine, USC, 1200 North
State Street, Los Angeles, California 90033, USA. E-mail: campese@usc.edu
Received 1 June 2006; revised 21 July 2006; accepted 1 August 2006;
published online 11 October 2006
2116
http://www.kidney-international.
& 2006 International Society of Nephrology
Kidney International (2006) 70, 21162123. doi:10.1038/sj.ki.5001854;
published online 11 October 2006
KEYWORDS: aldosterone; spironolactone; proteinuria; glomerular filtration
rate; chronic kidney disease; hyperkalemia
Background
The prevalence of chronic kidney disease (CKD) is increasing
alarmingly mainly as a result of an ongoing epidemic of
obesity, metabolic syndrome, and diabetes mellitus.1
Several factors may contribute to the progression of CKD
including derangements of renal hemodynamics, vasoactive
hormones such as angiotensin II and norepinephrine,
cytokines, growth factors, oxidative stress, and inflamma-
tion.24 Numerous studies have demonstrated that the
reninangiotensinaldosterone system (RAAS) plays an im-
portant role in the progression of CKD,5,6 and inhibition of
the RAAS with angiotensin-converting enzyme inhibitors
(ACEIs) and angiotensin type 1 receptor antagonists (ARBs)
may retard CKD progression.710 These renoprotective effects
are attributed to reduction of systemic arterial and
glomerular pressures and to inhibition of angiotensin-II-
related effects on mesangial cell proliferation and fibrosis.11
However, neither ACEIs nor ARBs abrogate the progression
of kidney disease. This suggests that ACEIs and ARBs, at the
doses currently approved, do not predictably suppress
aldosterone in all patients, a phenomenon known as
aldosterone synthesis escape, leaving potentially detrimental
effects of aldosterone unabated.12
Studies in experimental rat models have shown that
aldosterone participates to the progression of kidney disease
through hemodynamic and direct cellular actions13 and
antagonists of aldosterone retard the progression or cause
regression of existing glomerulosclerosis independently of
effects on blood pressure (BP).1416
The clinical evidence for a role of aldosterone in CKD
progression is scanty.1720 In a pilot short-term uncontrolled
study, we observed that spironolactone effectively reduced
proteinuria in non-diabetic CKD patients already treated
with ACEIs and/or ARBs.21
This is a prospective, randomized open-label study to
evaluate the effects of spironolactone, an aldosterone receptor
Kidney International (2006) 70, 21162123
S Bianchi et al.: Spironolactone and chronic kidney disease original article

antagonist, on proteinuria and estimated glomerular filtra-
tion rate (eGFR) in a cohort of 165 CKD patients treated for
1 year.
RESULTS
The baseline and follow-up clinical characteristics of all
patients included in the study are shown in Tables 1 and 2.
The baseline clinical characteristics of patients treated
with spironolactone did not differ from those of patients
treated with conventional therapy. Baseline proteinuria was
2.170.08 g/g creatinine in patients treated with spirono-
lactone and 2.070.07 g/g creatinine in patients treated with
conventional therapy. After 1 year of follow-up, proteinuria
decreased to 0.8970.06 g/g creatinine among patients treated
with spironolactone, but it did not change among patients
treated with conventional therapy (Table 3). In 23 out of 78
patients treated with spironolactone for 1 year, proteinuria
decreased to o500 mg/g creatinine. Baseline proteinuria was
greater among patients with eGFRo60 ml/min/1.73 m2 than
among those with eGFR460 ml/min/1.73 m2 (2.1770.08 vs
1.8270.07 g/g creatinine in the conventional therapy group
and 2.3370.09 vs 1.8470.08 g/g creatinine in the group of
patients treated with spironolactone) (Table 3). After 1 year
of treatment with spironolactone, the percent decline in
proteinuria was significantly greater among patients with
estimated GFRo60 than among patients with estimate
GFR460 ml/min/1.732 (62.2 vs 42.9%, Po0.01) (Table 3,
Figure 1).
After 1 year of treatment with spironolactone, the percent
reduction in proteinuria was greater among patients treated
with ACEIs (60.974.8%) or ARBs alone (67.973.6%)
than among patients treated with a combination of ACEIs
and ARBs (42.875.5%, Po0.01) (Table 5).
After 4 weeks of treatment with spironolactone, eGFR
decreased from 62.472.4 to 57.372.7 ml/min/1.732
(Po0.001) (Table 4). Thereafter, eGFR remained stable and
at the end of 12 months treatment was 58.672.6 ml/min/
1.732. By contrast, during 1 year of follow-up, eGFR declined
slowly but progressively in subjects treated with conventional
therapy (from 62.272.1 to 56.472.3 ml/min/1.732, Po0.01)
(Table 4, Figure 2). At the end of 1 year of treatment,
eGFR was not statistically different between the two groups.
However, the percent decline in eGFR was lower in patients
treated with spironolactone than in controls (Figure 2). Also,
the monthly rate of decrease in eGFR from baseline was lower
in patients treated with spironolactone than in controls
(0.32370.044 vs 0.47470.037 ml/min, Po0.01). The reduc-
tion in eGFR observed during treatment with spironolactone
was more pronounced among patients with estimated
GFRo60 ml/min than among patients with GFR460 ml/
min/1.73 m2 (Table 4). After 1 year of treatment, we observed
a weak but statistically significant correlation between the
percent changes in proteinuria and changes in eGFR in the
entire group of patients studied (r 0.307 Po0.0001). This
relationship was significant only for patients treated with
spironolactone (r 0.350, Po0.0001) and not for patients
treated with conventional therapy. The relationship between
the percent change in proteinuria and change in eGFR
was already present after the first month of treatment with
spironolactone (r 0.436, Po0.0001).

Table 1 | Clinical characteristics at baseline of patients treated with conventional therapy and those receiving conventional
therapy plus spironolactone 25 mg/day
All Conventional therapy Conventional therapy plus spironolactone
No. of patients 165 82 83
Age (years) 54.770.8 54.471.2 55.071.2
Sex (M/F) 106/59 50/32 56/27
BMI 24.970.2 24.870.2 24.970.2
Smokers (Y/N) 41/124 21/61 19/64
Basal SBP (mmHg) 132.370.5 131.670.6 132.970.8
Basal DBP (mmHg) 78.370.3 78.170.4 78.570.5
eGFR (ml/min/1.73 m2) 62.371.6 62.272.1 62.472.4
Uprotein (g/g creatinine) 2.170.05 2.070.07 2.170.08
Serum K+ (mEq/l) 4.370.03 4.270.03 4.270.04
Basal aldosterone (pg/ml) 132.174.7 130.476.5 134.776.9

Antihypertensive drugs
ACEIs 50 21 29
ARBs 35 18 17
Both ACEIs and ARBs 80 43 37

Other antihypertensive drugs

Number (O/1/2/3) 20/69/60/16 8/36/34/4 12/33/26/12
Diuretics (Y/N) 116/49 56/26 60/23
Statins (Y/N) 146/19 72/10 74/9
ACEIs, angiotensin-converting enzyme inhibitors; ARBs, angiotensin type 1 receptor antagonists; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood
pressure; F, female; M, male; K+, potassium; N, no; Y, yes; eGFR; estimated glomerular filtration rate.
Data are expressed as mean7s.e.m.

Kidney International (2006) 70, 21162123 2117

original article S Bianchi et al.: Spironolactone and chronic kidney disease

Table 2 | Blood pressure, estimated GFR and serum potassium Table 3 | Effect of spironolactone on proteinuria in patients
levels at baseline and during follow-up in patients treated with eGFRo or 460 ml/min/1.73 m2
with conventional therapy and those treated with
Conventional
conventional therapy plus spironolactone Conventional therapy plus
Conventional therapy spironolactone
Conventional therapy plus Basal all 2.070.07 2.170.08
therapy spironolactone eGFRo60 ml/min 2.1770.08 2.3370.09
Blood pressure (mmHg) eGFR460 ml/min 1.8270.07** 1.8470.08**
Basal SBP 131.670.6 132.970.8
Basal DBP 78.170.4 78.570.5 1 month all 2.070.07 1.4970.06 (26.9%)*
1 month eGFRo60 ml/min 2.1670.08 1.6270.09 (29.8%)
SBP 130.870.6 131.470.8 eGFR460 ml/min 1.8970.07 1.3170.07 (22.8%)
DBP 77.370.7 77.870.5
3 months 3 months all 1.9770.07 1.2670.06 (37.9%)*
SBP 130.770.6 131.370.9 eGFRo60 ml/min 2.0170.08 1.3470.09 (42.3%)
DBP 76.570.9 78.370.6 eGFR460 ml/min 1.8970.07 1.1570.07 (31.5)**
6 months
SBP 130.370.6 129.570.9 6 months all 1.9770.07 1.1370.06 (43.9%)*
DBP 76.570.9 76.970.6 eGFRo60 ml/min 2.1470.08 1.1970.09 (48.5%)
9 months eGFR460 ml/min 1.8670.07 1.0570.08 (37.2%)#
SBP 130.570.6 128.570.9*
DBP 77.570.5 76.570.5** 9 months all 2.070.07 0.9970.06 (49.9%)*
12 months eGFRo60 ml/min 2.170.08 1.070.08 (56.4%)
SBP 130.270.6 126.970.8**,# eGFR460 ml/min 1.9470.07 0.9870.08 (40.%)**
DBP 77.370.5 75.670.5**,@
12 months all 2.1170.08 0.8970.06 (54.2%)*
Estimated GFR (ml/min/1.73 m2) eGFRo60 ml/min 2.1970.09 0.8870.09 (62.2%)
Basal 62.272.1 62.472.4 eGFR460 ml/min 1.9970.08 0.9370.09 (42.9%)**
1 month 61.172.2 57.372.7* eGFR, estimated glomerular filtration rate.
3 months 59.772.3 56.672.7* In parentheses are the % changes vs basal proteinuria.
6 months 58.672.2* 57.872.7* *Po0.001 vs basal proteinuria.
#
9 months 57.472.3* 58.072.6* Po0.05 vs patients with eGFRo60 ml/min.
**Po0.01 vs patients with eGFRo60 ml/min.
12 months 56.472.3** 58.672.6*

Serum potassium (mEq/l)

Basal 4.270.03 4.270.04 from 4.270.04 at baseline to 5.070.05 mEq/l (Po0.001) at
1 month 4.370.03 4.570.05**,# the end of 1 year of treatment. By contrast, serum potassium
3 months 4.370.04 4.770.05**,#
6 months 4.370.05 4.770.07**,#
did not change in patients treated with conventional therapy.
9 months 4.370.05 4.870.05**,# Four patients in the spironolactone arm and two in the
12 months 4.370.05 5.070.05**,# conventional therapy arm of the study, all with estimated
DBP, diastolic blood pressure; GFR, glomerular filtration rate; SBP, systolic blood GFRo60 ml/min, reached a serum potassium level 45.5 but
pressure. o6.0 mEq/l and had to discontinue the study. Baseline serum
Data are expressed as mean7s.e.m.
*Po0.05 vs basal. potassium levels were higher (Po0.005) in patients treated
**Po0.001 vs basal.
#
with a combination of ACEIs and ARBs (4.470.07 mEq/l)
Po0.001 vs conventional therapy.
@
Po0.03 vs conventional therapy. than in those treated with ARBs alone (4.270.08 mEq/l).
Baseline serum potassium levels were not different in patients
treated with a combination of ACEIs and ARBs (4.47
Baseline BP in patients randomized to conventional 0.07 mEq/l) than in those treated with ACEIs alone (4.37
therapy was 131.670.6/78.170.4 mmHg and in patients 0.08 mEq/l) (Table 5). The effects of spironolactone treat-
randomized to spironolactone was 132.970.8/78.57 ment on serum K were not different in patients treated
0.5 mmHg. After 9 and 12 months of therapy with spiro- with a combination of ACEIs and ARBs than in those treated
nolactone, BP decreased (Po0.05) in patients treated with with ACEIs or ARBs alone (Table 5).
spironolactone (128.370.8/76.370.5 and 126.970.8/75.670.5, Baseline plasma aldosterone levels were not different
respectively) but not in the control group (130.570.6/77.570.5 between patients treated with conventional therapy and
and 130.270.6/78.170.7, respectively) (Table 2). No those randomized to spironolactone (130.476.5 and 134.77
effect of spironolactone on BP was evident during the first 6.9 pg/ml, respectively). Aldosterone levels were lower
6 months of treatment. (Po0.001) among the 35 patients receiving ACEIs and ARBs
Baseline serum potassium was not different between combined (89.674.9 pg/ml) than the 27 patients receiving
patients treated with conventional therapy and those rando- ACEIs alone (165.777 pg/ml) and the 16 patients receiving
mized to spironolactone (4.270.03 and 4.270.04 mEq/l, ARBs alone (18179.7 pg/ml) (Table 5).
respectively) (Table 2). However, during treatment with Baseline levels of aldosterone were significantly correlated
spironolactone, serum potassium increased progressively with levels of proteinuria (r 0.766, Po0.0001) (Figure 3)

2118 Kidney International (2006) 70, 21162123

S Bianchi et al.: Spironolactone and chronic kidney disease original article

Table 4 | Effect of spironolactone 25 mg/day on renal function Table 5 | Clinical characteristics at baseline and end of the
in patients with eGFRo or 460 ml/min/1.73 m2 study in patients treated with spironolactone in addition to
ACEIs alone, ARBs alone, or a combination of ACEIs and ARBs
Conventional
Conventional therapy plus ACEIs ARBs ACEIs+ARBs
therapy spironolactone
No. of patients 27 16 35
Basal eGFR 62.272.1 62.472.4 Age 57.672.1 53.372.9 53.771.7
eGFRo60 ml/min 49.571.7 46.571.3 Sex (M/F) 17/10 11/5 25/10
eGFR460 ml/min 80.172.2 85.372.3 BMI 24.970.5 24.870.6 24.970.3

1 month 61.172.2 57.372.7# Other antihypertensive drugs

% Reduction vs basal (O/1/2/3) 2/16/6/3 3/8/3/2 6/7/16/6
#
All patients 1.67/0.2 8.270.8
eGFRo60 ml/min 2.370.3 13.670.8# Diuretics (Y/N) 19/8 10/6 22/13
eGFR460 ml/min 0.770.3 4.170.9* Statins (Y/N) 25/2 14/2 32/3

3 months eGFR 59.772.3 56.672.7# Basal aldosterone (pg/ml) 165.777 18179.7 89.674.9*
% Reduction vs basal
#
All patients 3.670.4 9.170.8 Basal SBP (mmHg) 132.871.9 136.571.7 131.371.3
eGFRo60 ml/min 5.670.5 15.170.9# Basal DBP (mmHg) 78.470.8 80.370.9 77.770.9
eGFR460 ml/min 1.870.4 4.670.9*
Basal serum potassium (mEq/l) 4.370.08 4.270.08 4.470.07**
6 months eGFR 58.672.2# 57.872.7 % Increase at 12 months 5.070.08 4.870.07 5.170.09**
% Reduction vs basal
All patients 5.570.4# 7.570.8# Basal proteinuria (g/g creatinine) 2.3870.1 2.7970.1 1.5970.09#
eGFRo60 ml/min 8.270.5# 12.870.9# % Reduction at 12 months 60.974.8 67.973.6 42.875.5*
eGFR460 ml/min 3.170.5* 3.470.7*
Basal eGFR (ml/min/1.73 m2) 55.573.6 58.474.9 69.774*
9 months eGFR 57.472.3# 58.072.6# % Reduction at 12 months 6.771.3 8.171.4 6.771.5
% Reduction vs basal
ACEIs, angiotensin-converting enzyme inhibitors; ARBs, angiotensin type 1 receptor
All patient 7.470.6# 7.270.7# antagonists; BMI, body mass index; DBP, diastolic blood pressure; F, female; M, male;
eGFRo60 ml/min 11.470.6# 10.070.9# N, no; SBP, systolic blood pressure; Y, yes.
eGFR460 ml/min 4.370.7* 4.270.7* *Po0.01 vs patients treated with ACEIs or ARBs alone.
#
Po0.05 vs patients treated with ACEIs and ARBs.
12 months eGFR 56.472.3# 58.672.6# **Po0.005 vs patients treated with ARBs.
% Reduction vs basal Five of the original patients randomized to spironolactone did not complete the
All patient 9.070.6#,# 6.270.7# study owing to adverse events. These patients are not included in this analysis.
eGFRo60 ml/min 13.570.7# 8.170.9#
eGFR460 ml/min 5.770.7* 3.970.7*
Months of treatment
eGFR, estimated glomerular filtration rate (ml/min/1.73 m2) by Modification of Diet
1 3 6 9 12
in Renal Disease formula.
*Po0.01 vs patients with eGFRo60 ml/min; #Po0.001 vs baseline eGFR.
2
% reduction of eGFR vs basal value

Months of treatment
6
1 3 6 9 12
0

% reduction of proteinuria vs basal value

20
* Conventional therapy
* *
40 * *
* *
* *
*#
60
80 All patients
Patients with GFR<60 ml/min
Patients with GFR>60 ml/min
Figure 1 | This slide shows the percent reduction of proteinuria
from baseline in patients treated with spironolactone (25 mg/
day) in addition to conventional therapy divided on the basis
of their eGFR (o or 460 ml/min/1.73 m2). *Po0.001 vs basal
proteinuria; #Po0.05 vs patients with eGFR o60 ml/min; @Po0.01
vs patients with eGFR o60 ml/min.
8
10
Conventional therapy+Spironolactone
12
* Figure 2 | This slide shows the percent decline in eGFR in patients
* treated with spironolactone and those treated with conventional
*@ * therapy. Patients were followed for 1 year. *Po0.001 vs basal eGFR,
**Po0.0001 vs basal eGFR.
*@
and with the percent reduction in proteinuria following
treatment with spironolactone (r 0.42, Po0.0002).
Single regression analyses showed that the level of urine
protein excretion at 12 months was significantly correlated
with systolic (r 0.272, Po0.001) and diastolic BP (r
0.242, Po0.002), and with the change in eGFR after 1 month
of treatment with spironolactone (r 0.459, Po0.0001).

Kidney International (2006) 70, 21162123 2119

original article
Step-wise multiple linear regression analyses using 12
months percentage reduction of proteinuria as a dependent
variable and systolic and diastolic BP, plasma aldosterone,
eGFR, and baseline proteinuria as independent explanatory
variables showed that systolic BP at 12 months (P 0.02),
basal aldosterone (P 0.017), and the percent change in
eGFR at 1 month (P 0.004), but not eGFR at 12 months
(P 0.06) and basal proteinuria (P 0.56) predicted the
reduction in proteinuria with spironolactone treatment.
Adverse events and dropouts
Nine patients did not complete the study, five in the
spironolactone group and four in the control group. In the
spironolactone group, four patients discontinued treatment
after 3 months because of persistent serum K 45.5 mEq/l
despite diuretic therapy and low K diet. All these subjects
had eGFRo60 ml/min/1.73 m2 and three out of four were
taking a combination of ACEIs and ARBs; the fourth patient
was taking an ACEI. One patient developed significant
gynecomastia and discontinued treatment after 3 months.
Five additional patients treated with spironolactone devel-
oped mild gynecomastia that did not necessitate disconti-
nuation of the drug. In the control group, four patients
discontinued therapy during the first 3 months, two for
hyperkalemia, and two were lost to follow-up. All patients
with hyperkalemia had baseline eGFRo60 ml/min/1.732.
DISCUSSION
In this long-term study, we have confirmed that spirono-
lactone can substantially reduce urine protein excretion in
patients with CKD. This effect occurred in patients with the
RAAS inhibited by ACEIs and/or ARBs for at least 1 year
before the initiation of treatment with spironolactone and it
was sustained throughout the period of observation.
In a previous study, we showed that treatment with 25 mg
of spironolactone for 8 weeks reduced proteinuria from
2.0970.16 to 1.0570.08 g/24 h. The reduction in proteinuria
was apparent as early as 2 weeks after initiation of treatment
4 with early diabetic nephropathy and aldosterone escape
3.5
Basal proteinuria, g/g creatinine
3 with spironolactone. Of note, the decrease in urine albumin
2.5
2 nuric effects of spironolactone with that of cilazapril in 60
1.5
1 administration of the ACEIs and spironolactone was more
0.5
0 50 100 150 200
Basal aldosterone, pg /ml
Figure 3 | This slide shows the regression line between baseline
plasma aldosterone levels and proteinuria in the 165 patients
included in the study (r 0.766, Po0.0001).
2120
S Bianchi et al.: Spironolactone and chronic kidney disease
and reverted to baseline 4 weeks after discontinuation of
the drug.21
The observed early reduction in proteinuria was not
related to changes in BP since it was evident after 1 month of
treatment with spironolactone, at a time when there was no
significant change in BP. Significant effects of spironolactone
on BP became evident only after 9 and 12 months of
treatment. After 12 months, multiple regression analyses
showed a contribution of BP to proteinuria reduction.
Chrysostomou et al.22 observed a 50% decrease in proteinur-
ia in CKD patients without significant changes in BP.
The baseline levels of proteinuria were lower among
patients treated with a combination of ACEIs and ARBs than
among those treated with any of these drugs alone. This is in
line with the study of Nakao et al.23 who showed greater
reduction of proteinuria with a combination of trandolapril
and losartan than with any of these drugs alone23 and
suggests that ACEIs and ARBs when given alone even at the
highest approved doses may provide incomplete RAAS block-
ade. The beneficial effects of spironolactone on proteinuria in
patients with already suppressed RAAS by ACEIs or ARBs can
be best explained by inadequate suppression of aldosterone
secretion.24 The percent decline in proteinuria with spirono-
lactone was less pronounced among patients who received a
combination of ACEIs and ARBs than among patients who
received ACEIs or ARBs alone. It is noteworthy that the
baseline levels of aldosterone were lower among patients
treated with a combination of ACEI and ARBs than among
patients treated with any of these classes of drugs alone. This
is in keeping with the notion that levels of aldosterone are an
important determinant of the degree of proteinuria and of
the pharmacological response to spironolactone in CKD
patients. In support of this hypothesis is also the strong
correlation we observed between baseline levels of aldoster-
one and levels of proteinuria.
Before this study, there was limited evidence that
antagonists of aldosterone reduce proteinuria in CKD
patients. In an uncontrolled trial of eight patients with
various renal diseases and proteinuria 41 g per day, spiro-
nolactone consistently reduced proteinuria.25 In 13 patients
from ACEIs, Sato et al.20 observed a significant reduction
in urinary albumin excretion after 24 week of treatment
excretion was more pronounced among patients with aldo-
sterone escape. Rachmani et al.19 compared the antiprotei-
female with diabetic nephropathy. Spironolactone reduced
proteinuria more effectively than ACEIs and the combined
effective than either drug alone. Epstein et al.26 observed that
250 300
eplerenone reduced proteinuria more effectively than an
ACEI in patients with type II diabetes mellitus and the combi-
nation of eplerenone and ACEI was more effective than either
drug given alone in reducing proteinuria. Spironolactone
treatment in addition to recommended antihypertensive
Kidney International (2006) 70, 21162123
S Bianchi et al.: Spironolactone and chronic kidney disease
drugs reduced BP and proteinuria in type I and type II
diabetic patients with nephropathy.27,28
This study is also the first to suggest that spironolactone
may reduce the rate of decline in kidney function in CKD
patients. Baseline eGFR was not different in the two groups of
patients studied. However, in patients treated with spirono-
lactone we observed an initial rapid (after 1 month) decline
in eGFR, followed by stabilization. By contrast, in patients
treated with conventional therapy, eGFR declined slowly but
progressively. By the end of 1-year treatment, the percent
decline in eGFR was significantly greater in patients treated
with conventional therapy than in those treated with
spironolactone.
The mechanisms responsible for the initial acute reduc-
tion in eGFR are unclear. However, this phenomenon is
reminiscent of the initial fall in eGFR seen in CKD patients
treated with ACEIs, whereby an initial rapid decrease in GFR
is usually followed by stabilization of kidney function.7
Schmidt et al.29 have shown that aldosterone exerts rapid
nongenomic effects on the renal vasculature resulting in
increased renal vascular resistance and increased filtration
fraction. These effect of aldosterone on the renal vasculature
occurred only when endothelial NO synthase was inhibited
by simultaneous administration of NG monomethyl-L-
arginine. In an editorial accompanying the article by Schmidt
et al.,29 Chun and Pratt30 suggest that under conditions of
endothelial dysfunction, as it might occur in patients with
essential hypertension, metabolic syndrome, or CKD, these
nongenomic effects of aldosterone might result in reduced
renal blood flow and GFR. Using isolated afferent and
efferent arterioles from rabbit kidneys, Arima et al.31 have
shown that aldosterone exerts a vasoconstrictive action on
both the afferent and efferent arterioles, but the sensitivity
of the efferent arterioles to aldosterone was greater than that
of the afferent arterioles. Interestingly, the vasoconstrictor
effects of aldosterone were not blocked by spironolactone
suggesting that the vasoconstrictor action is non-genomic.
Endothelial denudation and pharmacological blockade of
eNOS increased the sensitivity of the afferent arterioles
to aldosterone suggesting that nitric oxide modulates the
vasoconstrictor action of aldosterone.32 In a dog model of
obesity-induced hypertension, both BP and GFR decreased
after treatment with eplerenone.33 In all, these studies suggest
that antagonists of aldosterone may exert intrarenal hemo-
dynamic changes resulting in an acute decrease in GFR.
After this initial rapid fall, eGFR remained stable
throughout the rest of the year of treatment with spirono-
lactone and the average percent decline in eGFR was signi-
ficantly lower in patients treated with spironolactone than in
those treated with conventional therapy. These findings are
consistent with the wealth of experimental evidence showing
aldosterone may contribute to renal injury34,35 and antago-
nists of this hormone may result in renal protection. In 5/6
nephrectomized rats with subtotal nephrectomy and adrenal-
ectomy, proteinuria hypertension and structural renal injury
were less pronounced than in rats with intact adrenal
Kidney International (2006) 70, 21162123
original article
glands.36 Aldosterone infusion abrogated the beneficial effects
of ACEIs in stroke-prone spontaneously hypertensive rats,
whereas spironolactone reduced vascular injury and protein-
uria in these animals.14,15
The mechanisms responsible for the adverse effects of
aldosterone on the kidney are complex. As a result of
differential effects on the afferent and efferent glomerular
arterioles, aldosterone could increase intraglomerular pres-
sure, an action reminiscent of that of angiotensin II. Experi-
mental evidence has shown that aldosterone may damage
non-epithelial tissues, in the heart, brain, kidneys, and blood
vessels.3742 Aldosterone stimulates type IV collagen accu-
mulation in rat mesangial cells and this may result in
progressive renal fibrosis.43 Aldosterone stimulates plasmino-
gen activator inhibitor-1, which is centrally involved in the
pathogenesis of fibrinolysis and it may contribute to
glomerulosclerosis and tubulo-interstitial nephritis.44,45
Aldosterone stimulates transforming growth factor-b1, a
cytokine that promotes fibroblast differentiation and pro-
liferation,46 and aldosterone antagonists improve experimen-
tal chronic cyclosporine nephrotoxicity.47 Eplerenone inhibits
lectine-like oxidized low-density lipoprotein receptor-1-
mediated adhesion molecules and results in improved endo-
thelial function.48 In 4-week-old Dahls salt-sensitive rats
fed high-salt diet, Nagase et al.49 observed proteinuria and
glomerulosclerosis associated with a decrease in nephrin and
an increase in markers of podocyte damage, such as B7-1 and
desmin. Treatment with eplerenone dramatically improved
podocyte damage and retarded progression of proteinuria
and glomerulosclerosis.
Although 25 mg spironolactone appeared to be well
tolerated in this population at increased risk for hyper-
kalemia, owing to stage 34 CKD and co-administration of
ACEIs and ARBs, caution should be exercised when using
this drug in patients with eGFR below 60 ml/min. The low
incidence of hyperkalemia in our study might be due to close
clinical observation, adjustment of dietary intake of potas-
sium and dose of diuretics and should not be taken as an
indication for liberalized use of this drug in CKD patients.
Our study has several limitations. Although we observed
lower degree of progression of CKD in patients treated with
spironolactone, the number of patients included and the
duration of the study were not adequate to clearly establish a
long-term beneficial effect of spironolactone on progression
of kidney disease. Prospective randomized trials on larger
groups of patients and longer duration than 1 year are
necessary to more adequately address this issue.
The study was open label and not placebo controlled.
Therefore, potential bias in the evaluation of data cannot be
completely excluded. Finally, the limitations of using eGFR
instead of measured GFR are well known and have been the
object of extensive reviews.50,51
In conclusion, this study has demonstrated that antago-
nists of aldosterone reduce proteinuria in patients with CKD.
This effect occurs in addition to that obtained with the
administration of inhibitors of the RAS. The study also
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original article
suggests that spironolactone may reduce the rate of
progression of CKD. However, larger prospective randomized
studies of longer duration are needed to conclusively
demonstrate beneficial effects of aldosterone antagonists on
the progression of CKD. Concerns remain in regards to the
risk of hyperkalemia particularly in patients with more
advanced kidney disease.
MATERIALS AND METHODS
This is a prospective, open-label randomized study to evaluate the
effects of spironolactone on proteinuria and eGFR and the safety of
this drug in CKD patients. The Human Research Committee of the
Spedali Riuniti di Livorno, Italy, approved the study and all subjects
gave their informed consent. The randomization was performed
using a computed generated system.
The clinical characteristics of patients included in the study are
illustrated in Tables 1 and 2. We enrolled 165 CKD patients (106
males and 59 females) with eGFR ranging from 34 to 116 ml/min/
1.73 m2 and proteinuria ranging from 1.0 to 3.9 g/g creatinine. These
subjects were screened among more than 400 patients with CKD
followed in our outpatient clinic. To be included, all patients had to
have a clinical diagnosis of idiopathic chronic glomerulonephritis
based on the presence of proteinuria greater than 1.0 g/g creatinine,
and no evidence of systemic diseases. In 62 of these patients, the
diagnosis of chronic glomerulonephritis was confirmed by a renal
biopsy: 33 patients had IgA nephropathy, five membrano-prolifera-
tive glomerulonephritis, 14 focal and segmental glomerulosclerosis,
eight membranous glomerulonephritis, and two had micro-
scopic vasculitis. In patients who were not biopsied, we cannot
exclude the possibility of renal diseases other than glomerulone-
phritis.
One hundred and twenty-two patients were hypertensive (office
systolic BPX140 mmHg and diastolic BPX90 mmHg). We excluded
patients with diabetes mellitus, renovascular or malignant hyper-
tension, secondary glomerular disease, malignancies, myocardial
infarction, or cerebrovascular accident within the 6 months prece-
ding the study, congestive heart failure, hepatic dysfunction, serum
potassium 45 mEq/l, eGFRo30 ml/min/1.73 m2, and a history
of allergy to ACEIs or ARBs. We also excluded patients treated
with steroids, nonsteroidal anti-inflammatory drugs, or immuno-
suppressive agents.
Before inclusion in this trial, all patients had been followed in the
outpatient clinic for at least 1 year and treated with ACEIs and/or
ARBs. In the control group, 21 subjects were treated with ACEIs,
18 with ARBs, and 43 with a combination of these two classes of
drugs. In the spironolactone group, 28 patients were treated with
ACEIs, 17 with ARBs and 38 with a combination of ACEIs and
ARBs. Fifty-six patients in the conventional therapy group and 60 in
the spironolactone group received hydrochlorothiazide or furose-
mide. Other antihypertensive drugs were used as needed to achieve a
target BP of o125/75 mmHg, and 74 patients achieved this target.
The doses of ACEIs and ARBs were not changed after randomization
and inclusion in the study. The dose of diuretics was increased in
patients who developed hyperkalemia in an attempt to control
serum potassium before deciding to withdraw patients from the
study. Seventy-two patients in the conventional therapy group and
74 in the spironolactone group received atorvastatin (2040 mg/day)
for at least 1 year before the initiation of this study. Patients were
advised to ingest a diet with approximately 23 g sodium per day,
and if eGFR was lower than 60 ml/min/1.73 m2, they were counseled
2122
S Bianchi et al.: Spironolactone and chronic kidney disease
to ingest a protein intake of 0.8 g/kg/day. We did not measure
urinary sodium and urea excretion to assess compliance with these
dietary restrictions.
The baseline evaluation included measurements of BP, heart rate,
urine protein excretion, eGFR, and plasma aldosterone levels. After
the baseline evaluation, 83 patients were randomized to receive
spironolactone 25 mg/day and 82 continued conventional therapy.
Thereafter, patients were seen in the clinic after 1, 3, 6, 9, and 12
months. At each clinic visit, BP and heart rate were measured at least
three times after sitting for 30 min and a blood sample was drawn.
At each clinic visit, including the baseline evaluation, each subject
was asked to bring three spot morning urine samples obtained on 3
consecutive days for the measurement of urine protein/creatinine
ratio. The average of these three samples was recorded.
Analytic procedures
BP was measured by mercury sphygmomanometer. Body mass index
(BMI) was calculated as weight (kg) divided by height (m) squared.
Urinary protein, serum creatinine, and potassium were measured
by standard methods. Glomerular filtration rate was estimated using
the Modification of Diet in Renal Disease formula.52 Plasma
aldosterone was measured by a commercially available kit (Nichols
Advantage Aldosterone, Nichols Institute Diagnostics, San Clem-
ente, CA, USA).
For statistical analysis, we used the Students t-test for parametric
parameters and the KolmogorovSmirnov test for comparison of
non-parametric parameters. We used univariate analyses to assess
correlations between baseline urinary protein excretion and eGFR,
age, gender, systolic and diastolic BP, percent change in urinary
protein excretion, and plasma aldosterone levels. Any covariates that
were significant in univariate analyses were assessed by step-wise
multiple linear regression analyses. Changes in urine protein
excretion, office BP, and eGFR were analyzed by repeated-measures
analysis of variance.
ACKNOWLEDGMENTS
This study was supported with private funding. No support was
received by pharmaceutical companies. Drs Bianchi and Bigazzi
have participated in the planning, performance of the study and
preparation of this paper. Dr Campese has only participated in the
planning of the study, evaluation of data, and preparation of this
paper.
REFERENCES
1. US renal data system: excerpts from USRDS 2005 annual report.
Am J Kidney Dis 2006; 47(Suppl 1): S17S144.
2. Myers BD, Deen WM, Brenner BM. Effects of norepinephirne and
angiotensin II on the determinants of glomerular ultrafiltration and
proximal tubule fluid reabsorption in the rat. Circ Res 1995; 37:
101110.
3. Egido J. Vasoactive hormones and renal sclerosis. Kidney Int 1996; 49:
578597.
4. Remuzzi G, Ruggenenti P, Benigni A. Understanding the nature of renal
disease progression. Kidney Int 1997; 51: 215.
5. Ibrahim HN, Rosenberg ME, Hostetter TH. Role of the reninangiotensin
aldosterone system in the progression of renal disease: a critical review.
Semin Nephrol 1997; 17: 431440.
6. Anderson S, Rennke HG, Brenner BM. Therapeutic advantage of
converting enzyme inhibitors in arresting progressive renal disease
associated with systemic hypertension in the rat. J Clin Invest 1986; 77:
19932000.
7. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of
angiotensin-converting-enzyme inhibition on diabetic nephropathy.
The Collaborative Study Group. N Engl J Med 1993; 329:
14561462.
Kidney International (2006) 70, 21162123
S Bianchi et al.: Spironolactone and chronic kidney disease
8. Andersen S, Tarnow L, Rossing P et al. Renoprotective effects of
angiotensin II receptor blockade in type 1 diabetic patients with
diabetic nephropathy. Kidney Int 2000; 57: 601606.
9. Brenner BM, Cooper ME, De Zeeuw D, et al., for the RENAAL Study
Investigators. Effects of losartan on renal and cardiovascular outcomes in
patients with type 2 diabetes and nephropathy. N Engl J Med 2001; 345:
861869.
10. Lewis EJ, Hunsicker LG, Clarke WR et al. Renoprotective effect of the
angiotensin-receptor antagonist irbesartan in patients with nephropathy
due to type 2 diabetes. N Engl J Med 2001; 345: 851860.
11. Ma LJ, Fogo AB. Role of angiotensin II in glomerular injury. Semin Nephrol
2001; 21: 544553.
12. McElvie RS, Yusuf S, Pericak D et al. Comparison of candesartan, enalapril,
and their combination in congestive heart failure: randomized evaluation
of strategies for left ventricular dysfunction (RESOLVD) pilot study.
Circulation 1999; 10: 10561064.
13. Greene E, Kren S, Hostetter TH. Role of aldosterone in the remnant kidney
model in the rat. J Clin Invest 1996; 98: 10631068.
14. Rocha R, Chander PN, Khanna K et al. Mineralocorticoid blockade reduces
vascular injury in stroke-prone hypertensive rats. Hypertension 1998; 31:
451458.
15. Rocha R, Chander PN, Zuckerman A, Stier CT. Role of aldosterone in renal
vascular injury in stroke-prone hypertensive rats. Hypertension 1999; 33:
232237.
16. Aldigier JC, Kanjanbuch T, Ma LJ et al. Remission of existing glomerulo-
sclerosis by inhibition of aldosterone. JASN 2005; 16: 33063314.
17. Hene RJ, Boer P, Koomans HA, Dorhout Mees EJ. Plasma aldosterone
concentration in chronic renal failure. Kidney Int 1982; 21: 98101.
18. Berl T, Katz FH, Henrich WL et al. Role of aldosterone in the control of
sodium excretion in patients with advanced chronic renal failure. Kidney
Int 1978; 14: 228235.
19. Rachmani R, Slavachevsky I, Amit M et al. The effects of spironolactone,
cilazapril and their combination on albuminuria in patients with
hypertension and diabetic nephropathy is independent of blood pressure
reduction: a randomized controlled study. Diabetes Med 2004; 21:
471475.
20. Sato A, Hayashi K, Saruta T. Effectiveness of aldosterone blockade in
patients with diabetic nephropathy. Hypertension 2003; 41: 6468.
21. Bianchi S, Bigazzi R, Campese VM. Antagonists of aldosterone and
proteinuria in patients with CKD: an uncontrolled pilot study. Am J Kidney
Dis 2005; 46: 4551.
22. Chrysostomou A, Pedagogos E, MacGregor L et al. Double-blind,
placebo-controlled study on the effects of the aldosterone receptor
antagonist spironolactone in patients who have persistent proteinuria
and are on long-term angiotensin-converting enzyme inhibitory therapy,
with or without an angiotensin II receptor blocker. Clin J Am Soc Nephrol
2006; 1: 256262.
23. Nakao N, Yoshimura H, Morita M et al. Combination treatment of
angiotensin-II receptor blocker and angiotensin-converting enzyme
inhibitor in non-diabetic renal disease (COOPERATE): a randomized
controlled trial. Lancet 2003; 361: 117124.
24. Shiigai T, Shichiri M. Late escape from the antiproteinuric effects of ACE
inhibitors in non diabetic renal disease. Am J Kidney Dis 2001; 37:
477483.
25. Chrysostomou A, Becker G. Spironolactone in addition to ACE inhibition
to reduce proteinuria in patients with chronic renal disease. N Engl J Med
2001; 345: 925926 (Letter to the Editor).
26. Epstein M, Weinberger M, Lewin A et al. The selective aldosterone blocker
eplerenone reduces proteinuria without concomitant hyperkalemia.
J Am Soc Nephrol 2003; 14: 6A.
27. Schjoedt KJ, Rossing K, Juhl TR et al. Beneficial impact of spironolactone
in diabetic nephropathy. Kidney Int 2005; 68: 28292836.
28. Rossing K, Schjoedt KJ, Smidt U et al. Beneficial effects of adding
spironolactone to recommended antihypertensive treatment in diabetic
nephropathy. Diabetes Care 2005; 28: 21062112.
29. Schmidt BMW, Sammer U, Fleischmann I et al. Rapid non genomic effects
of aldosterone on the renal vasculature in humans. Hypertension 2006;
47: 650655.
Kidney International (2006) 70, 21162123
original article
30. Chun TY, Pratt JH. Non genomic renal effects of aldosterone. Dependency
on NO and genomic actions. Hypertension 2006; 47: 636637.
31. Arima S, Kohagura K, Xu HL et al. Non genomic vascular action of
aldosterone in the glomerular microcirculation. J Am Soc Nephrol 2003;
14: 22552263.
32. Arima S, Kohagura K, Xu HL et al. Endothelium-derived nitric oxide
modulates vascular action of aldosterone in renal arteriole. Hypertension
2004; 43: 352357.
33. De Paula RB, da Silva AA, Hall JE. Aldosterone antagonism attenuates
obesity-induced hypertension and glomerular hyperfiltration.
Hypertension 2004; 43: 4147.
34. Epstein M. Aldosterone as a mediator of progressive renal disease:
pathogenetic and clinical implications. Am J Kidney Dis 2001; 37:
677688.
35. Hollenberg NK. Aldosterone in the development and progression of renal
injury. Kidney Int 2004; 66: 19.
36. Quan ZY, Walser M, Hill GS. Adrenalectomy ameliorates ablative
nephropathy in the rat independently of corticosterone maintenance
level. Kidney Int 1992; 41: 326333.
37. Bonvalet JP, Alfaidy N, Farman N, Lombes M. Aldosterone: intracellular
receptors in human heart. Eur Heart J 1995; 16(suppl N): 9297.
38. Delyani JA, Robinson EL, Rudolph AE. Effect of a selective aldosterone
receptor antagonist in myocardial infarction: effect on infarct healing and
left ventricular remodeling. Am J Physiol Heart Circ Physiol 2001; 281:
H647H654.
39. Kornel L, Ramsay C, Kanamarlapudi N et al. Evidence for the presence in
the arterial walls of intracellular-molecular mechanism for action of
mineralocorticoids. Clin Exper Hypertens 1982; 4: 15611582.
40. Roland BL, Krozowski ZS, Funder JW. Glucocorticoid receptor,
mineralocorticoid receptors, 11 beta-hydroxysteroid dehydrogenase-1
and -2 expression in rat brain and kidney: in situ studies. Mol Cell
Endocrinol 1995; 111: R1R7.
41. Sun Y, Ramires FJ, Weber KT. Fibrosis of atria and great vessels in
response to angiotensin II or aldosterone infusion. Cardiovasc Res 1997;
35: 138147.
42. Tanaka J, Fujita H, Matsuda S et al. Glucocorticoid- and mineralocorticoid
receptors in microglial cells: the two receptors mediate differential effects
of corticosteroids. Glia 1997; 20: 2337.
43. Watisaka M, Spiro MJ, Spiro RG. Synthesis of type IV collagen by
cultured glomerular cells and comparison of its regulation by glucose
and other factors with that of type IV collagen. Diabetes 1995; 43:
95103.
44. Brown NJ, Agirbasli MA, Williams GH et al. Effect of activation and
inhibition of the reninangiotensin system on plasma PAI-I. Hypertension
1998; 32: 95971.
45. Eddy AA. Plasminogen activator inhibitor-1 and the kidney. Am J Physiol
Renal Physiol 2002; 283: F209F220.
46. Sun Y, Zhang J, Zhang JQ, Ramires FJA. Local angiotensin II and
transforming growth factor-b in renal fibrosis in rats. Hypertension 2000;
35: 10781084.
47. Feria I, Pichardo I, Juarez P et al. Therapeutic benefit of spironolactone in
experimental chronic cyclosporine A nephrotoxicity. Kidney Int 2003; 63:
4352.
48. Kobayashi N, Hara K, Tojo A et al. Eplerenone shows renoprotective effect
by reducing LOX-1mediated adhesion molecule, PKCe-MAPK-p90RSK,
and Rho-Kinase Pathway. Hypertension 2005; 45: 538544.
49. Nagase M, Shibata S, Yoshida S et al. Podocyte injury underlies the
glomerulopathy of Dahl salt-hypertensive rats and is reversed by
aldosterone blocker. Hypertension 2006; 47: 10841093.
50. Poggio ED, Hall PM. Estimation of glomerular filtration rate by
creatinine-based formulas: any room for improvement? NephSAP 2006; 5:
131140.
51. Levey AS, Coresh J, Balk E et al. National Kidney Foundation practice
guidelines for chronic kidney disease: evaluation, classification, and
stratification. Ann Int Med 2003; 139: 137147.
52. Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney
disease: evaluation, classification, and stratification. Am J Kidney Dis 2002;
39: S1S266.
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