Treatment with a combination of low-density lipoprotein aphaeresis and pravastatin of a patient with drug-resistant nephrotic syndrome due to focal segmental glomerulosclerosis

Low Density Lipoprotein Apheresis for Treatment of Focal Segmental Glomerulosclerosis

Focal segmental glomerulosclerosis (FSGS) has become one the leading causes of kidney disease in the United States. With the incidence of FSGS rising over the past decade, capable treatment options have been a large focus in research. One therapy that shows promise is low density lipoprotein apheresis (LDL-A). This procedure removes lipoproteins containing apolipoprotein-B from the blood, thus reducing the lipid load on the renal system. LDL-A also improves responsiveness to the standard FSGS therapy of corticosteroids and cyclosporine. This paper describes the current LDL-A techniques, offers insight to existing clinical studies employing this therapy, and ultimately highlights LDL-A as a treatment option for FSGS, post-renal transplant, and nephrotic syndrome.

Establishment of relapse risk model and multivariate logistic regression analysis on risk factors of relapse in children with primary nephrotic syndrome

This study aimed to investigate relapse risk factors in children with primary nephrotic syndrome (PNS) for prevention and early intervention via logistic regression. One hundred thirty-seven children with PNS were enrolled in this study. Clinical variables were analyzed by single-factor and multiple regression analysis to establish the regression equation. The predictive ability of the regression equation was investigated by the receiver operating characteristic curve (ROC). Files of 17 patients were lost, and 120 patients were enrolled finally in the study, among whom 55 cases (45.8%) had frequently relapsed. Single-factor analysis and multiple regression analysis revealed that concurrent infection on first onset, irregular glucocorticoid therapy, severe hypoalbuminemia, and persistent severe hyperlipidemia were the significant risk factors for frequent relapse on PNS (P < .05), among which infection remained to be the main inductive factor. Among the 4 indicators, serum albumin had the best diagnostic efficacy based on the area under the ROC curve (0.933), sensitivity (89.09%), and specificity (81.54%). The area under curve, sensitivity, and specificity for the combined diagnostic model of the 4 indices were 97.8%, 98.18%, and 90.77%, respectively, which had good predictive power for the relapse of patients. Concurrent infection, irregular glucocorticoid therapy, severe hypoalbuminemia, and persistent severe hyperlipemia were all the risk factors for PNS relapse. The established logistic regression model based on these factors above is reliable for predicting frequent PNS relapse. Much attention should be paid to these critical factors, and early intervention should be taken to reduce the incidence of relapse.

Low-density lipoprotein apheresis for recurrent focal segmental glomerulosclerosis post renal transplant in pediatric patients

Low-density lipoprotein (LDL) apheresis has been shown to improve remission in patients with steroid-resistant nephrotic syndrome (SRNS). Here, we report a case study of two patients who failed apheresis treatment for SRNS and required transplant with subsequent recurrence of nephrotic syndrome and response to apheresis treatment. Two patients were treated with 12 sessions of LDL apheresis for SRNS without improvement and subsequently required renal transplantation. The first patient received an ABO-incompatible kidney transplant requiring plasma exchange (PE) with subsequent recurrence of focal segmental glomerulosclerosis. The second patient also received a renal transplant after treatment failure and subsequently developed recurrence of nephrotic syndrome in the transplanted kidney. Both patients underwent repeat therapy with lipoprotein apheresis. The first patient underwent lipoprotein apheresis after completing PE with significant improvement in serum creatinine and urine protein creatinine ratio. Three years later, he continued to do well and remains in remission. The second patient also responded well to repeat therapy with lipoprotein apheresis and had significant improvement with a urine protein creatinine ratio of 0.8 and a serum creatinine of 0.9 mg/dL 6 months after transplant. Lipoprotein apheresis was able to result in remission of nephrotic syndrome in these patients with posttransplant recurrence of disease. This is the first report of patients not responding to treatment pretransplant but responding posttransplant. Lipoprotein apheresis should be considered in patients with recurrence of nephrotic syndrome after renal transplantation even with a history of treatment failure prior to transplantation.

Liposorber® LA-15 system for LDL apheresis in resistant nephrotic syndrome patients

BACKGROUND

Steroid-resistant nephrotic syndrome (SRNS) is a major cause of stage 5 chronic kidney disease (CKD 5) in children. LDL apheresis (LDL-A) is now FDA approved for the treatment of pediatric focal segmental glomerulosclerosis (FSGS). Effective management of hyperlipidemia with LDL-A in SRNS patients may prevent progression of kidney disease and lead to remission. We report a case series of patients who received LDL-A for treatment of SRNS METHODS: We describe five children with SRNS who were treated with 12 sessions of LDL-A. Partial remission (PR) is defined as urine protein to creatinine ratio (UPC) of 0.2-2 (g/g) or decrease in UPC ≥ 50%, and complete remission (CR) is defined as UPC < 0.2 (g/g).

RESULTS

One patient achieved CR and three achieved PR. One patient did not respond to therapy. The earliest that a patient achieved PR was at treatment #10 and some did not respond until after LDL-A was completed. Those who responded stayed in either CR or PR for extended periods of time. LDL-A was successful at significantly reducing LDL (p < 0.001), total cholesterol (p < 0.001), and triglyceride (p < 0.001).

CONCLUSIONS

LDL-A was able to significantly decrease the lipid levels in these patients and induce CR and PR in the majority. The current study confirms previous studies showing those with a higher glomerular sclerosis burden were less likely to respond. LDL-A should be considered in patients with treatment-resistant SRNS and should be considered before there is a high burden of glomerular sclerosis to provide the best chance of success.

An update on LDL apheresis for nephrotic syndrome

Low-density lipoprotein (LDL) apheresis has been used increasingly in clinical practice for the treatment of renal diseases with nephrotic syndrome (NS), specifically focal segmental glomerulosclerosis (FSGS). Persistent hyperlipidemia for prolonged periods is nephrotoxic and leads to chronic progressive glomerular and tubulointerstitial injury. Effective management of hyperlipidemia with HMG-CoA reductase inhibitors or LDL apheresis in drug-resistant NS patients may prevent the progression of renal disease and, in some patients, resolution of NS symptoms. Available literature reveals beneficial effects of LDL apheresis for NS refractory to drug therapy. Here we update on the current understanding of lipid nephrotoxicity and application of LDL apheresis to prevent progression of renal diseases.

Dextran-Sulfate Plasma Adsorption Lipoprotein Apheresis in Drug Resistant Primary Focal Segmental Glomerulosclerosis Patients: Results From a Prospective, Multicenter, Single-Arm Intervention Study

Background: Focal segmental glomerulosclerosis (FSGS) causes end stage renal disease (ESRD) in significant proportion of patients worldwide. Primary FSGS carries poor prognosis and management of FSGS patients, refractory to standard treatments or resistant to steroids, remains a major challenge. Lipoprotein apheresis is a therapeutic approach for drug resistant primary FSGS and post-renal transplant primary FSGS recurrence. Objectives: To examine the safety and probable benefit at 1, 3, 6, 12, and 24-months following completion of apheresis treatment using Liposorber® LA-15 system in patients with nephrotic syndrome (NS), due to refractory primary FSGS or primary FSGS associated NS, in post renal transplant children. Material and Methods: Prospective, multicenter, single-arm intervention study using Liposorber® LA-15 system. Patients ≤21 years old with drug resistant or drug intolerant NS secondary to primary FSGS with glomerular filtration rate (GFR) ≥60 ml/min/1.73 m² or post renal transplant patients ≤21 years old with primary FSGS associated NS were included in the study. Each patient had 12 dextran-sulfate plasma adsorption lipoprotein apheresis sessions over a period of 9 weeks. All patients were followed up at 1, 3, 6, 12, and 24-months following completion of treatment. Results: Of 17 patients enrolled, six were excluded from the outcome analysis (protocol deviations). Of the remaining 11 patients, all but one have completed apheresis treatments. Three patients were lost to follow-up immediately after completion of apheresis and excluded from outcome analysis. At one-month follow-up, 1 of 7 patients (14.3%) attained partial remission of NS while 2 of 4 subjects (50%) and 2 of 3 subjects (66.7%) had partial/complete remission at 3- and 6-months follow-up, respectively. One of two patients followed up for 12 months had complete remission and one patient had partial remission of NS after 24 months. Improved or stable eGFR was noted in all patients over the follow-up period. Conclusion: The results of our multicenter study showed improvement in the response rates to steroid or immunosuppressive therapy and induced complete or partial remission of proteinuria in some of the patients with drug resistant primary FSGS. The main limitation of our study is the small number of subjects and high dropout rate.

Efficacy and safety of Monascus purpureus Went rice in children and young adults with secondary hyperlipidemia: a preliminary report

BACKGROUNDS/AIMS

Nephrotic dyslipidemia is a risk factor for development of systemic atherosclerosis; also it may aggravate glomerulosclerosis and enhance progression of glomerular disease. We aimed to assess the efficacy and safety of Monascus purpureus Went rice vs. fluvastatin therapy in the management of nephrotic dyslipidemia.

METHODS

Seventy-two patients with idiopathic persistent nephrotic syndrome with secondary dyslipidemia were included. They were randomly allocated into 3 - age and sex - matched groups. The first group comprised of 20 cases and were given Monascus purpureus Went rice, second group comprised 30 cases were given fluvastatin. The remaining 22 received no anti-dyslipidemic therapy and constituted a control group. All of these patients were subjected to thorough laboratory investigations including renal function tests, lipogram and neurological assessment.

RESULTS

Our results showed that both fluvastatin and Monascus purpureus Went rice were well-tolerated with no significant side effects. Both of them significantly reduced cholesterol after 6 months and 1 year. In comparison to baseline values, fluvastatin achieved a significant and progressive reduction of serum cholesterol by 35%, 38% and 42% at 3 months, 6 months and after 1 year respectively (p<0.001). Similar reductions were observed in the Monascus purpureus Went rice group. After one year we observed that serum cholesterol was significantly lower in statin and Monascus purpureus Went rice groups compared to the control group.

CONCLUSION

Monascus purpureus Went rice is safe, effective cholesterol lowering agent for nephrotic dyslipidemia both in adults and children.

Monascus purpureus Went rice in nephrotic hyperlipidemia

BACKGROUND

Nephrotic dyslipidemia is a risk factor for the development of systemic atherosclerosis; and may aggravate glomerulosclerosis and enhance progression of glomerular disease. We aimed to assess the efficacy and safety of Monascus purpureus Went rice vs. fluvastatin therapy in the management of nephrotic dyslipidemia.

MATERIALS AND METHODS

Seventy-two patients with persistent idiopathic nephrotic syndrome (NS) with secondary dyslipidemia were included. They were randomly allocated into three age and sex-matched groups. The first group comprised 20 cases and were given M. purpureus Went rice in a dose of 600 mg twice/day for 1 month then once daily, the second group comprised 30 cases were given fluvastatin in a daily dose of 20 mg. The remaining 22 received no antidyslipidemic therapy and constituted a control group. All of these patients were subjected to thorough laboratory investigations including renal function tests and lipogram. Moreover, the neuromuscular status was evaluated with electromyography and nerve conduction velocity.

RESULTS

Our results showed that both fluvstatin and M. purpureus Went rice were well tolerated with no evidence of significant side effects including neuromuscular functions. Both of them significantly reduced cholesterol after 6 months and 1 year.

CONCLUSION

Monascus purpureus Went rice is safe, effective, and economic treatment strategy for nephrotic dyslipidemia.

Long-term efficacy of low-density lipoprotein apheresis for focal and segmental glomerulosclerosis

Recently, there have been reports on the efficacy of low-density lipoprotein (LDL) apheresis (LDL-A) for focal and segmental glomerulosclerosis (FSGS) in pediatric patients. However, there have been few reports on the long-term efficacy of LDL-A for FSGS in such patients. We report here a case of long-term efficacy of LDL-A for FSGS. The patient was a 13-year-old boy with FSGS who presented with steroid-resistant and cyclosporine-resistant nephrotic syndrome and hyperlipidemia. LDL-A was performed 24 times on one year. Following LDL-A, serum concentrations of LDL, very low-density lipoprotein (VLDL), apoprotein B, and vascular endothelial growth factor significantly decreased, and urinary excretion of protein also decreased. In addition, 3 years after LDL-A, the pathology findings on a second renal biopsy had improved. The patient has been in remission from FSGS for 12 years since LDL-A. These findings suggest that LDL-A may be useful in maintaining long-term remission from pediatric FSGS.

Clinical applications of long-term LDL-apheresis on and beyond refractory hypercholesterolemia

Premature coronary heart disease (CHD) can result from high LDL cholesterol levels even in the absence of any other risk factors. A striking example is found in children who have the homozygous form of familial hypercholesterolemia (FH) with extremely high levels of LDL-cholesterol, and severe atherosclerosis and CHD often develop during the first decades of life. LDL-apheresis was developed for the treatment of severe type of FH patients who are resistant to lipid-lowering drug therapy. Clinical efficacy and safety of the therapeutic tool which directly removes LDL from circulation have already been established in the treatment for refractory hypercholesterolemia in FH patients. The most recently developed method enables lipoproteins to be adsorbed directly from whole blood, using polyacrylate column. In addition to benefits derived from the stabilization or regression of arterial lesions, we highlight other possible clinical applications of LDL-apheresis. However, most of these clinical benefits came from case reports or retrospective studies. Mechanisms related these clinical improvement remain unclear, and prospective randomized controlled trials should be performed for the new clinical indications of LDL-apheresis.

A combined low-density lipoprotein apheresis and prednisone therapy for steroid-resistant primary focal segmental glomerulosclerosis in children

BACKGROUND

Treatment of steroid-resistant (SR) primary focal segmental glomerulosclerosis (FSGS) remains a major challenge in nephrology. A prospective study was conducted to clarify the therapeutic role of low-density lipoprotein apheresis (LDL-A) in 11 nephrotic children with SR and cyclosporine A (CsA)-resistant primary FSGS.

METHODS

Based on entry criteria, all 11 eligible patients had biopsy-proven primary FSGS presenting with nephrotic syndrome (NS) and were resistant to steroid and conventional-dose CsA therapy. LDL-A was performed twice a week for 3 weeks (first course), then weekly for 6 weeks (second course). Beginning from the second LDL-A course, a dosage of 1 mg/kg/d of prednisone was administered for 6 weeks, then tapered.

RESULTS

Seven patients experienced remission of NS, 5 of whom achieved complete remission within 4 weeks after initiating prednisone therapy with LDL-A. These 5 patients maintained normal renal function during follow-up (median, 4.4 years). Of 2 patients with partial remission, 1 patient maintained stable renal function during follow-up (4.5 years), whereas the other patient showed a gradual decline in renal function and progressed to end-stage renal failure (ESRF) 7.8 years after LDL-A therapy. Four patients who were considered to experience treatment failure had persistent NS and progressed to ESRF in 1.3 years (median) after LDL-A therapy. Complete remission (n = 5) was associated with significantly more highly selective proteinuria compared with treatment failure (n = 4).

CONCLUSION

This study suggests that combined LDL-A and prednisone therapy can be a valuable addition to therapeutic options for treating patients with SR-FSGS. The role of LDL-A in treating these patients deserves to be assessed further in larger randomized controlled trials.

Other immunosuppressive agents for focal segmental glomerulosclerosis

A prolonged course with corticosteroids represents the first therapeutic approach for nephrotic patients with focal segmental glomerulosclerosis (FSGS). In patients with contraindications to steroids or in those who do not respond to steroids or cyclosporine, cytotoxic agents, mycophenolate mofetil (MMF), plasmapheresis, and low-density lipoprotein (LDL) apheresis have been tried as alternative treatments. A short-term treatment with cytotoxic agents often is ineffective in steroid-resistant patients However, an aggressive and prolonged treatment with cytotoxic agents combined with corticosteroids proved to be effective in more than half of steroid-resistant children. In adults, the response to cytotoxic agents was good in steroid-responsive patients, but was poor in steroid-resistant patients. Better results were observed when cytotoxic therapy was prolonged for several months. The problem with these drugs is that long-term immunosuppression may be complicated by severe side effects including a major risk for cancer. Uncontrolled studies reported that MMF can induce some reduction of proteinuria, but complete remission of proteinuria was rare and no data on long-term follow-up evaluation with this drug are available. Good results have been reported with plasmapheresis, immunoadsorption, and lipopheresis. However, all the reports were uncontrolled, small sized, and with short-term follow-up evaluation. In conclusion, there are several therapeutic options for patients who respond to steroids and have further relapses of nephrotic syndrome, but how to treat steroid-resistant patients is still a matter of debate. Nevertheless, a 6-month trial with cytotoxic agents or MMF can be offered to steroid-resistant patients to identify the few patients who respond to these agents. The preliminary results with plasmapheresis or lipopheresis are promising but further studies are needed to assess the role of these treatments.

Low-density lipoprotein apheresis for the treatment of refractory hyperlipidemia

The advent of treatment with 3-hydroxy-3-methylglutaryl coenzyme A inhibitors has meant that, with a combination of diet and drug therapy, adequate control of serum cholesterol concentrations can be achieved in most patients with hypercholesterolemia. However, some patients, primarily those with familial hypercholesterolemia (FH), may require additional therapy to lower their cholesterol levels. In recent years, low-density lipoprotein (LDL) apheresis has emerged as an effective method of treatment in these patients. The criteria for commencement of LDL apheresis are LDL cholesterol levels of 500 mg/dL or higher for homozygous FH patients, 300 mg/dL or higher for heterozygous FH patients in whom medical therapy has failed, and 200 mg/dL or higher for heterozygous FH patients with documented coronary disease and in whom medical therapy has failed. In addition to cholesterol lowering in patients with FH, other indications for LDL apheresis are emerging. These include its use in the treatment of graft vascular disease in patients receiving cardiac transplants as well as in the treatment of certain glomerulonephritides. This review examines the role of LDL apheresis in the management of lipid disorders and the evidence available to support its use in clinical practice.

New Aspects of the Treatment of Nephrotic Syndrome

Abstract.The nephrotic syndrome, caused by glomerulonephritis, diabetes mellitus, or amyloidosis, is still a therapeutic challenge. Newer therapeutic approaches may be sought in the fields of immunosuppression, nonspecific supportive measures, heparinoid administration, and removal of a supposed glomerular basement membrane toxic factor. In immunosuppression, the newer drugs now used in organ transplantation (cyclosporine, tacrolimus, and mycophenolate mofetil) can also be used in the treatment of glomerulonephritis. In nonspecific supportive treatment, angiotensin II receptor antagonists are now used in addition to angiotensin-converting enzyme inhibitors. Positive effects of hydroxymethylglutaryl coenzyme A reductase inhibitors on the nephrotic syndrome have not yet been proven. Cyclooxygenase II inhibitors must be tested but probably have too many renal side effects, similar to those of nonsteroidal anti-inflammatory drugs. Heparinoids or glycosaminoglycans serve as polyanions and thus have protective effects on the negative charge of the glomerular basement membrane. They can now be administered as oral medications. The removal of a supposed glomerular basement membrane toxic factor that induces proteinuria has been attempted for 20 yr and now is usually performed using immunoadsorption. Especially in cases of recurrent nephrotic syndrome after renal transplantation for patients with glomerulonephritis, this approach has been successful in decreasing proteinuria, although in most cases its effect is not lasting but must be continuously renewed.

Effect of protein A immunoadsorption in nephrotic syndrome of various etiologies

Protein A immunoadsorption (IA) has proved effective in reducing proteinuria in patients with nephrotic syndrome after recurrence of focal and segmental glomerulosclerosis (FSGS) in kidney transplants. The effect of IA in nephrotic syndrome of other etiologies remains unknown. Nine patients with nephrotic syndrome secondary to membranous nephropathy (four cases), diabetes mellitus (one case), IgA nephropathy (two cases), and amyloidosis (two cases) had three to five IA of 2.5 plasma volumes over 4 to 8 d. Patients received no concomitant immunosuppressive treatment, and antihypertensive drugs were left unchanged. Proteinuria decreased from 12.64 +/- 5.49 to 3.35 +/- 2.2 g/24 h (mean +/- SD) in all patients after three to five IA. Hematocrit decreased from 37.32 to 32.64% (12.5% hemodilution) and serum albumin from 25.43 to 18.6 g/L (26.4% decrease). Proteinuria returned to baseline levels within 1 mo, as described in recurrent FSGS following transplantation. When serum albumin balance was controlled by albumin infusion after IA in two patients, comparable decreases in proteinuria were observed. Therefore, IA is effective in producing short-term reduction of proteinuria in nephrotic syndromes related not only to FSGS but also to membranous and IgA nephropathies, diabetes mellitus, and amyloidosis, which suggests that IA removes a nonspecific circulating hemodynamic-altering or permeability-increasing factor.

Lipopheresis in the nephrotic syndrome

BACKGROUND

Experimental models have established a role for lipoproteins in the pathogenesis of progressive renal failure. However, conventional treatment rarely normalizes the high serum cholesterol of the nephrotic syndrome. The removal of low-density lipoprotein by lipopheresis is discussed.

METHODS

Lipopheresis may be beneficial in nephrotic patients with focal segmental glomerulosclerosis. The authors studied the long-term effects of low-density lipoprotein cholesterol (LDL-C) removal using the Kaneka Liposorber system, which binds LDL-C to dextran sulfate in a controlled trial in 20 nephrotic patients with different renal diseases.

RESULTS

A 21-month clamp of plasma total cholesterol at 6.0 mmol/liter or below was significantly lower than controls (chi 2 = 84.3, P < 0.001), followed 12 aphereses over 6 to 12 weeks in all but three apheresed patients. 1/Cr slopes were unchanged when the 50-day average period of lipopheresis treatments was excluded from analysis. Proteinuria was not reduced, but serum albumin tended to rise (NS). Fibrinogen fell by 29.8%; high-density lipoprotein, apoA1, and Lp(a) were unchanged. Two apheresed patients had a prolonged remission with a reduction of proteinuria to less than 250 mg/24 hr. The reasons for prolonged reduction of total cholesterol include depletion of tissue cholesterol, an improved fractional catabolic rate of very low density lipoprotein (VLDL), increased hepatocyte LDL turnover, and the maintenance of statin therapy.

CONCLUSION

Lipopheresis is a safe and effective method for the control of LDL in nephrotic syndrome. Early clamping of total cholesterol in the normal range resulted in a prolonged and significant reduction of LDL compared with controls.

Pravastatin. A reappraisal of its pharmacological properties and clinical effectiveness in the management of coronary heart disease

Pravastatin is an HMG-CoA reductase inhibitor which lowers plasma cholesterol levels by inhibiting de novo cholesterol synthesis. Pravastatin produces consistent dose-dependent reductions in both total and low density lipoprotein (LDL)-cholesterol levels in patients with primary hypercholesterolaemia. Favourable changes in other parameters such as total triglyceride and high density lipoprotein (HDL)-cholesterol levels are generally modest. Combination therapy with other antihyperlipidaemic agents such as cholestyramine further enhances the efficacy of pravastatin in patients with severe dyslipidaemias. Available data suggest that pravastatin is effective in elderly patients and in patients with hypercholesterolaemia secondary to diabetes mellitus or renal disease. The benefit of cholesterol-lowering in terms of patient outcomes is currently an area of considerable interest. Recently completed regression studies (PLAC I, PLAC II, KAPS and REGRESS) show that pravastatin slows progression of atherosclerosis and lowers the incidence of coronary events in patients with mild to moderately severe hypercholesterolaemia and known coronary heart disease. Large scale primary (WOSCOPS) and secondary (CARE) prevention studies, moreover, demonstrate that pravastatin has beneficial effects on coronary morbidity and mortality. In WOSCOPS, all-cause mortality was reduced by 22%. Pravastatin is generally well tolerated by most patients (including the elderly), as evidenced by data from studies of up to 5 years in duration. As with other HMG-CoA reductase inhibitors, myopathy occurs rarely (< 0.1% of patients treated with pravastatin): approximately 1 to 2% of patients may present with raised serum levels of hepatic transaminases. Thus, with its favourable effects on cardiovascular morbidity/mortality and total mortality, pravastatin should be considered a first-line agent in patients with elevated cholesterol levels, multiple risk factors or coronary heart disease who are at high risk of cardiovascular morbidity.

Plasma lipids and the progression of nephropathy in diabetes mellitus type II: effect of ACE inhibitors

Ninety-four normotensive type II diabetics with normal renal function and microalbuminuria were randomized to receive enalapril 10 mg/day or placebo and were followed for five years. In the patients treated by enalapril plasma creatinine values and albuminuria remained stable throughout the observation period. Their plasma total cholesterol decreased from an initial value of 245 +/- 27 mg/dl to mean study value of 236 +/- 29 mg/dl, and to a fifth year value of 232 +/- 27 mg/dl (P < 0.001). The changes in HDL cholesterol and triglyceride values were nonsignificant. In the placebo group there was a significant increase in albuminuria and a mean decline of 13% in reciprocal creatinine values during the five years. Plasma total cholesterol increased from an initial mean value of 246 +/- 24 to a mean study value of 252 +/- 25 mg/dl, and to a fifth year mean value of 259 +/- 32 mg/dl (P < 0.001). There was a significant correlation between both initial and mean plasma total cholesterol values, and the decline in renal function and the rise in albuminuria in the placebo treated patients. This correlation persisted after stratification for blood pressure. Treatment with enalapril did not eliminate these correlations. Cholesterol may be an additional risk factor for diabetic nephropathy. ACE inhibitors may have a modest cholesterol lowering effect in diabetic patients mediated, in part, through the decline in albuminuria.