1. Dick de Zeeuw Department of Clinical Pharmacology University Medical Center Groningen The Netherlands Albuminuria; a tool for measuring non-blood pressure related renal protection. Data from the RENAAL trial

2. RENAAL  Trial design: Rand control trial, double dummy intervention placebo vs losartan with conventional therapy background (without ACEi or ARB)  Population: 1513 type 2 diabetic nephropathy n Serum creatinine: 1.3 to 3 mg/dl n Albuminuria: > 300 mg/g  Dosing: 50 mg losartan or 100 mg if blood pressure >140/90  Measurements: n Albuminuria: morning void ACR; 24 hour Albumin and ACR in subgroup (n=710) n Proteinuria: 24 hour proteinuria, in subgroup (n=710)  Change in albuminuria: n Individual ACR change comparing baseline to 6 months  End-points: n Combined endpoint: Doubling serum creatinine, ESRD, Death n Single of each

3. RENAAL; AII-antagonist more renal protective than placebo in type 2 diabetes; similar blood pressure, different albuminuria % with event p=0.024 Risk Reduction: 16% Placebo Losartan 012243648 0 10 20 30 40 50 Systolic Diastolic MAP 012243648 Mo 60 80 100 120 140 160 Pulse Pressure Blood Pressure (mmHg) P L Brenner et al; New Engl J Med 2001 Albuminuria (Change,%) p=<0.001 35% Overall Reduction 40 012243648Mo -60 -40 -20 0 20 P L

4. Questions  Is Albuminuria a predictor of outcome?  Is it independent from other risk markers?  Is proteinuria different than albuminuria  Is spot sampling different than 24 hour  Is Albuminuria lowering predictive of outcome?  Is it independent from blood pressure lowering?  Is residual albuminuria predicting outcome?  Is Albuminuria a predictor of outcome?  Is it independent from other risk markers?  Is proteinuria different than albuminuria  Is spot sampling different than 24 hour  Is Albuminuria lowering predictive of outcome?  Is it independent from blood pressure lowering?  Is residual albuminuria predicting outcome?

5. RENAAL; Baseline proteinuria as a determinant for renal events in type 2 diabetic nephropathy De Zeeuw et al; Kidney Int 2004 Primary composite Endpoint 0 10 15 5 Hazard ratio <.52.02.954.4  5.25  Baseline Albuminuria (g/g) 0 <.52.02.954.45.25 ESRD 10 20 30  Hazard ratio

6. =0.00010.84 - 0.950.89 Hemoglobin (g/dL) <0.00010.61 - 0.800.70 Serum albumin (per 0.5 g/dL) <0.00011.7 – 2.52.1 Serum creatinine (mg/dL) <0.00014.4 - 8.7 6.2 Urine albumin:creatinine (log, mg/g) p-Value 95% Conf Interval Hazard Ratio* RENAAL; Model for independent renal risk factors during (optimal) blood pressure treatment in type 2 diabetic nephropathy (n=1300) Keane et al, Kidney Int 2003; and Keane et al, Clin J Am Soc Nephrol 2006 RENAAL RISK SCORE: (1.96 log [urinary albumin:creatinine ratio]) * (0.78 serum albumin [g/dl]) * (1.28 serum creatinine [mg/dl]) * (0.11 hemoglobin [g/dl]).

7. Questions  Is Albuminuria a predictor of outcome?  Is it independent from other risk markers?  Is proteinuria different than albuminuria  Is spot sampling different than 24 hour  Is Albuminuria lowering predictive of outcome?  Is it independent from blood pressure lowering?  Is residual albuminuria predicting outcome?  Is Albuminuria a predictor of outcome?  Is it independent from other risk markers?  Is proteinuria different than albuminuria  Is spot sampling different than 24 hour  Is Albuminuria lowering predictive of outcome?  Is it independent from blood pressure lowering?  Is residual albuminuria predicting outcome?

8. RENAAL; Albuminuria Reduction ( 30%) at Month 6 determines the renal outcome De Zeeuw et al; Kidney Int 2004 Renal Endpoint ESRD 012243648 Month 0 10 20 30 40 50 60 % with composite endpoint >30% <0% 012243648 Month 0 10 20 30 40 50 60 % with ESRD <0% >30%

9. RENAAL; Initial anti-albuminuric response predicts renal outcome Albuminuria reduction (%) -90-250255072 Albuminuria reduction (%) 0.0 0.5 1.0 1.5 2.0 2.5 Hazard ratio -90-250255072 Renal Endpoint ESRD 0.0 0.5 1.0 1.5 2.0 2.5 De Zeeuw et al; Kidney Int 2004

10. RENAAL; Antialbuminuric effect of losartan expIains the renal protective effect Outcome adjusted for albuminuria RR (97%CI)P valueRR (97%CI)P value Primary Composite 16.1 (2.5-27.8) 0.022 1.7 (-14.5- 15.5) 0.829 ESRD 28.6 (11.5-42.4) 0.002 14.1 (-6.6-30.8) 0.168 De Zeeuw et al; Kidney Int 2004

11. RENAAL; Response variability discordant for blood pressure and albuminuria Losartan N=715 Increased blood pressure (systolic) Decreased blood pressure (systolic) > +15 mmHg+15 to 0 mmHg0 to -15 mmHg > -15 mmHg Increased albuminuria >+30% 4.6%4.3%5.7%3.2% 0 to +30% 2.0%3.8%4.1%3.4% Decreased Albuminuria -30 to 0% 3.2%5.0%9.0%5.3% >-30% 5.6%8.5%15.9%16.6% Eijkelkamp et al; JASN 2007 151631 224769 3763

12. RENAAL; Differential effect of antihypertensive treatment on albuminuria and BP has differential effect on ESRD Eijkelkamp et al; JASN 2007

13. Questions  Is Albuminuria a predictor of outcome? n Is it independent from other risk markers? n Is proteinuria different than albuminuria n Is spot sampling different than 24 hour  Is Albuminuria lowering predictive of outcome? n Is it independent from blood pressure lowering?  Is residual albuminuria predicting outcome?

14. RENAAL; High residual albuminuria levels De Zeeuw et al; Kidney Int 2004 165 247 264 230 169 160 106 79 47 35 0 50 100 150 200 250 300 <.5.5-1.51.5-3.53.5-5.0>5.0 Losartan 0 mo (n=751) Losartan 6 mo (n=751) 158 155 272 252 196 189 99 123 37 43 0 50 100 150 200 250 300 <.5.5-1.51.5-3.53.5-5.0>5.0 Placebo 0 mo (n=762) Placebo 6 mo (n=762)

15. RENAAL: Residual high albuminuria and not residual high blood pressure determines risk for ESRD Eijkelkamp et al; JASN 2007

16. Summary  Is Albuminuria a predictor of outcome?YES n Is it independent from other risk markers?YES n Is proteinuria different than albuminuriaNO n Is spot sampling different than 24 hourNO  Is Albuminuria lowering predictive of outcome?YES n Is it independent from blood pressure lowering?YES  Is residual albuminuria predicting outcome? YES