danaparoid sodium lowers proteinuria in diabetic nephropathy
TRANSCRIPT
Danaparoid Sodium Lowers Proteinuria in Diabetic
Nephropathy
JOHAN W. VAN DER PIJL,* FOKKO J. VAN DER WOUDE,*
PETRONELLA H. L. M. GEELHOED�DUIJVESTIJN,t MARIJKE FROLICH,�
FELIX J. M. VAN DER MEER,� HERMAN H. P.J. LEMKES,” and
LEENDERT A. VAN ES,**Department of Nephrology, Leiden University Hospital, P0 Box 9600, 2300 RC Leiden, The Netherlands;tDepartment of Internal Medicine, Den Haag, The Netherlands; *Department of Clinical Chemistry, Leiden
University Hospital, Leiden, The Netherlands; �Department of Hematology, Leiden University Hospital,
Leiden, The Netherlands; ‘Department of Endocrinology, Leiden University Hospital, Leiden, The Netherlands.
Abstract. Diabetic nephropathy is a progressive renal disease
with thickening of the gbomerular basement membrane and
mesangial expansion and proliferation as histological hall-
marks. The presence of the glycosaminoglycan side chains of
heparan sulfate proteoglycan, an important constituent of the
glomerular basement membrane, is decreased in diabetic ne-
phropathy proportionally to the degree of proteinuria. Danap-
aroid sodium is a mixture of sulfated glycosaminoglycans
consisting mainly of heparan sulfate. The study presented here
involved performing a randomized placebo-controlled cross-
over study with danaparoid sodium in diabetic patients with
overt proteinuria. The aim of the study was to evaluate the
effect on proteinuria and safety/tolerability. Nine patients com-
pleted the study, without major side effects; the crossover
study consisted of two 6-wk periods of treatment with 750
anti-Xa units danaparoid sodium subcutaneously once-daily or
placebo. Following danaparoid sodium, significant declines of
both albuminuria and proteinuria were found. After danaparoid
sodium, the albumin excretion ratio standardized for urinary
creatinine reduced with 17% in comparison with an increase of
23% after placebo (95% confidence interval of the difference,
-75.9-3.9%; P = 0.03). The percentage change of the urinary
protein excretion corrected for urinary creatinine differed at 8
wk significantly between both treatment arms (P 0.001).
Additional parameters for safety as hematobogical, hemostasis,
biochemical parameters, and fundusphotography did not show
any clinically significant difference for both groups. Only two
patients had minor skin hematomas at the injection site while
using danaparoid sodium.
In conclusion, the supplementation was found to be feasible
and was not associated with side effects. A significant decline
of proteinuria was found. More prospective dose-finding and
long-term studies must be performed to see whether danap-
aroid sodium could not only induce a reduction of proteinuria
but also halt the progression of renal disease. (J Am Soc
Nephrol 8: 456-462, 1997)
Diabetic nephropathy occurs in 30%-40% of patients with
insulin-dependent diabetes melbitus (DM I). This type of renal
disease progresses over time and is strongly related to a high
mortality and morbidity rate (1-4). Proteoglycans and espe-
cially the glycosaminoglycan (OAO) side chains of heparan
sulfate (HS) are considered to be involved in the pathogenesis
of diabetic nephropathy. Heparan sulfate is thought to be
important for the gbomerular basement membrane (OBM) in
terms of structure and function. It prevents clogging of the
membrane and determines the sieving-function (5,6). HS is
mainly responsible for the negative-charge barrier in the OBM
(7), which is of relevance for preventing the passage of albu-
mm through the capillary wall. HS may also slow down mes-
angial expansion and proliferation (8-10). This is of utmost
Received September 5, 1996 Accepted November 1 1, 1996
Correspondence to Dr. J.W. van der Pijl, Department of Nephrobogy, C3-P, 1Leiden University Hospital, P0 Box 9600, 2300 RC Leiden, The Netherlands.
l046-6673/0803-0456$03.00/0
Journal of the American Society of Nephrology
Copyright (C) 1997 by the American Society of Nephrobogy
importance because mesangial expansion and proliferation are
both strongly correlated with decline of renal function (4,1 1).
A reduced synthesis and sulfatation of heparan sulfate proteo-
glycans by podocytes and mesangial cells, when cultured under
high glucose conditions, has been reported (12,13).
The key role of HS for the normal function of the OBM is
illustrated by the following findings: removal of HS by hepa-
rinitase (14) or shielding of HS by a monoclonal antibody (15)
generates albuminuria in vivo. In type I diabetic patients with
nephropathy, staining for heparan sulfate OAOs in the OBM is
reduced in proportion to the amount of proteinuria (16,17).
In the context of such a pivotal role of HS in diabetic
nephropathy, several studies have investigated whether supple-
mentation of sulfated glycosaminoglycans could be of any
benefit. Indeed, the development of diabetic nephropathy could
be prevented by giving glycosaminoglycans to rats with strep-
tozotocin-induced diabetes meblitus (18). Several clinical stud-
ies have reported preliminary results in type I diabetics with
micro- and macroalbuminuria. Myrup et a!. found a reduction
of microalbuminuria after treatment with low molecular weight
heparin (LMWH) and with standard heparin (19). In mac-
Danaparoid Sodium and Proteinuria 457
roalbuminuric patients treated with enoxaparin (a LMWH), a
significant decline of the urinary albumin excretion rate (AER)
was found, but significance was not reached in comparison
with the placebo treated group (20).
Danaparoid sodium is a new, commercially available, hep-
armnoid. It is a mixture of sulfated OAOs, consisting mainly of
HS with a small subfraction, which is highly sulfated. It is used
both for the prevention and treatment of venous thromboem-
bolism, where it has been shown to be efficacious and rela-
lively safe. It functions by augmenting the inhibitory action of
antithrombin on activated clotting factors Xa and ha. The high
ratio of anti-Xa/anti-IIa activity is thought to be responsible for
a good efficacy/safety profile. It is seldom associated with
heparin-induced thrombocytopenia. Clearance takes place
mainly by the kidneys (21-23). Therefore, and because dan-
aparoid sodium consists to a large extent of heparan sulfate, we
decided to study the effect of danaparoid sodium on proteinuna
in type I diabetic patients.
Materials and MethodsDesign
The study was designed as a phase II, randomized, double-blind,
placebo-controlled, crossover study. The medical ethical committee of
the Leiden University Hospital had approved the protocol of the study,
and all patients gave informed consent. Eligible patients were ran-
domly allocated to one of the two treatment groups: 750 anti-Xa units
danaparoid sodium (Orgaran#{174}, NV Organon, Oss, the Netherlands),
subcutaneously (SC) administered once daily for 6 wk; a wash-out
period of at least 4 wk; placebo (saline with sulfite), SC administered
once-daily for 6 wk, or the same scheme in the opposite direction.
Medical and laboratory assessments were performed every 2 wk (0 =
baseline; 2, 4, 6, and 8 wk after start of the respective treatments).
Patients
The study population consisted of nine patients who had nephrop-
athy due to DBM and fulfilled the following selection criteria: they
had to be > 18 years old; they had to have insulin-dependent diabetes
mellitus type I (DM I) with macroabbuminuria (AER >300 mg/24 h)
because of diabetic nephropathy and not because of other renal
disease; and they had to give informed consent. The use of angiotensin
I converting enzyme (ACE)-inhibitors and other antihypertensive
medications was only allowed if given at a stable dosage at least 6 wk
prior to start of the study.
Patients complying with the inclusion criteria were eligible if none
of the following exclusion criteria were present: pregnancy or wish to
become pregnant; hemorrhagic diathesis; use of medications known to
interfere with hemostasis and/or platelet function; use of corticoste-
roids; uncontrolled hypertension; active proliferative retinopathy; his-
tory of heparin-induced thrombocytopenia; severe hepatic failure;
creatinine clearance of <40 mL/min; hypersensivity to sulfite.
Medication
Danaparoid sodium is a mixture of sulfated GAGs, consisting of
84% heparan sulfate (HS), 12% dermatan sulfate, and 4% chondroitin
sulfate isolated from porcine intestinal mucosa. It has an average
molecular of weight 4000-7000 d, a specific anti-Xa activity of
11.0-17.0 U/mg, and an anti-Xa/anti-IIa ratio of >22. The elimina-
tion half-life of anti-Xa activity is -25 h. The half-life time is only
affected by severe renal failure, as seen in patients on chronic hemo-
dialysis. The placebo had the same appearance as the danaparoid
sodium containing ampoubes; it contained isotonic sodium chloride
and sodium sulfite. Danaparoid sodium (0.6 ml, 750 anti-Xa units)
and the placebo were administered once-daily by subcutaneous (SC)
injection for 6 wk, followed by a wash-out period of at least 4 wk. The
patients were trained to self-administer the study medication in an
abdominal skinfold. The date and time of each injection was recorded
daily by the patient on a list and checked by the investigator at the end
of each treatment period, together with the number of returned unused
ampoules. Protamine-containing insulin preparations were not al-
bowed to be injected at the same site, and study medication was not
allowed to be mixed with insulin.
Efficacy Assessments
In diabetic nephropathy, both proteinuria and macroalbuminuria
are associated with a steady decline of renal function. Taking the
relative short duration of treatment into account, we decided to use
proteinuria and albuminuria as surrogate markers. These parameters
were expressed per mmol of creatinine to correct for incomplete
urinary collections. The main parameters for efficacy were urinary
albumin excretion rate (AER) and urinary protein excretion rate
(PER) corrected for urinary creatinine excretion rate. Therefore, total
protein, albumin, and creatinine contents in 2 X 24-h urine samples
(collected by the subject at home) were assessed. Baseline measure-
ments were taken before both treatment periods. At 0, 4, 6, and 8 wk,
AER, PER, and creatinine clearance were measured twice, and the
means were compared with baseline (0 wk).
Safety Assessments
A general medical history (including duration of patients’ DM I),
height, weight, blood pressure, and heart rate after 3 mm in sitting
position were taken, and a medical examination was performed.
Fundusphotography (including staging of observed retinopathy) was
performed before the inclusion and at the end of the study period.
Sodium, potassium, urea, creatinine, glucose, total protein, albumin,
serum glutamic oxaboacetic transaminase (SOOT), serum glutamic
pyruvic transaminase (SOPT), alkaline phosphatase, yGT, HbA �,
hemoglobin, hematocrit, leukocytes, thrombocytes, prothrombin time,
antithrombin III, activated partial thromboplastin time (APTE’), and
plasma anti-Xa activity were tested regularly as safety and tolerability
parameters.
Laboratory Assessments
Urinary albumin was assessed using immunonephebometry on an
autoanalyser (Array Protein system, Beckman Instruments, Brea, CA)
with specific antibodies. Urinary protein, serum sodium, potassium,
urea, creatinine, protein, albumin, SGOT, SGPT, alkaline phospha-
tase, and yGT levels were assessed on a Hitachi 747 or 91 1 autoanal-
yser (Boehnnger, Mannheim, Germany). The Technicon H-l system
(Bayer Diagnostics, MUnchen, Germany) was used for the analysis of
hematobogical parameters. Prothrombin time was determined using
the Thromborel S reagent (Behringwerke AG, Marburg, Germany),
amd APTT was determined using the Cephotest reagent (Nyegaard,
Oslo, Norway), both on an Electra 1000C coagulometer (MLA, Pleas-
antville, NY). Antithrombin and anti-Xa activity were assessed on an
ACL 200 (Instrumentation Laboratory, Milan, Italy) with Coamatic
Antithrombin and Coatest LMWHeparin as reagents (Chromogenix,
M#{246}lndal, Sweden). HbAIC was assessed on high-performance liquid
chromatography (HPLC) after hemolysis.
458 Journal of the American Society of Nephrology
Table 1. Demographic dataa
Patientno.
Age(y)
Sex DM(y)
ACEi BMI(kg/rn2)
MAP(mmHg)
HbA1C(%)
AER(mg/24 h)
AER/Creat(mg/mmol)
PER/Creat(mg/mmol)
CrCb(mi/mm)
1 43 M 20 No 32.8 99 8.3 1000 64 90 119
2 52 M 28 Yes 29.8 100 7.5 1032 91 122 70
3 32 F 20 Yes 22.4 107 7.6 3044 250 368 62
4 33 M 24 No 27.1 107 7.4 968 63 97 127
5 35 M 31 No 27.6 113 10.8 715 95 103 54
6 44 M 25 Yes 28.7 103 7.7 912 64 86 141
7 29 M 16 No 22.1 105 7.4 670 52 72 68
8 29 M 26 Yes 23.9 103 7.4 258 21 35 96
9 25 M 14 No 28.7 107 9.8 403 46 70 79
a DM, diabetes mellitus type I; ACEi, yes denotes the use of ACE inhibitor, and no denotes no ACE inhibition; BMI, body mass index;
BP, blood pressure; MAP, mean arterial pressure; AER/creat, urinary albumin excretion rate standardized for urinary creatinine excretionrate; PER/creat, urinary protein excretion rate standardized for urinary creatinine excretion rate; CrCl, creatinine clearance.
Statistical Analyses
The mean change of the primary and secondary parameters duringthe two treatment periods were analyzed using a mixed-model anal-
ysis of variance (ANOVA), with random patient factor to account for
the correlations between the repeated measurement, and fixed treat-ment and time factors. In addition, single degree-of-freedom (paired t)
tests were used to evaluate differences between and within the two
treatment periods. Because the distribution of the primary parameters
was extremely skewed, a logarithmic transformation was applied. �values (relative change) for AERlcreat and PER/creat were calculated
as follows:
(y-x/x)* 100% = 6, where y is the nth week value for AERicreat or
PER/creat and x is the 0 week value. Significance was accepted at the
P-value level of 0.05. The calculations were performed with the SPSS
package release 6.0 for Windows.
ResultsPatients
Nine patients were enrolled in the study, and all completed
both crossover treatment periods. Prior to the study, two pa-
tients were treated with lasercoagulation for proliferative reti-
nopathy for ophthalmologic reasons only. Demographic data
and characteristics are given in Table 1 . In general, the HbAlc
reflected an acceptable metabolic control of the diabetes. In
contrast, the blood pressure was rather high for these patients.
The albuminuna and proteinuria ranged from borderline
“overt” (patient 8) to proteinuna in the nephrotic range (patient
3). Four patients were on ACE-inhibitors, and one of these also
used amlodipine. Table 2 shows the primary parameters per
group and treatment, Tables 3a and 3b show individual results.
HbAlc was 8.5% before the treatment period with danap-
aroid sodium and 8.3% before placebo (P = 0.4). No major
changes were made for the insulin dosage during both periods.
The baseline values of the MAP did not differ between the two
groups (103 mmHg and 105 mmHg; P = 0.3). No major
adverse events occurred. One patient needed antibiotic treat-
ment during the placebo period because of sinusitis without
fever. Subcutaneous injections were performed once daily dur-
Table 2. Creatinine clearance, blood pressure, AER/creatinine, and PER/creatinine before and after treatment with placebo
and danaparoid sodiuma
Danaparoid Sodium Placebo
0 wk 8 wk P value 0 wk 8 wk P value
CrC1 (mi/mm) 102.9
(75.5-1 30.4)
96.9
(68.4-1 25.4)
0.37 90.4
(74.0-106.8)
100.5
(69.7-131.4)
0.20
MAP (mm Hg)
AERlcreat (mg/mmol)
PER/creat (mg/mmol)
103.0
(100.6-105.4)
74.8
(42.7-1 3 1 .2)
111.0
(65.5-1 87.9)
102.2
(98.5-106.0)
60.6
(33. 1-1 10.9)
89.3
(5 1 .9-1 53.8)
0.68
0.03
0.008
105.4
(98.9-1 1 1.8)
64.8
(36.7-1 14.7)
87.0
(5 1 .9-146.0)
98.5
(92.7-104)
75.8
(37.2-154.3)
110.6
(57.4-213.1)
0.26
0.18
0.12
a All values are expressed as mean and (95% confidence interval of the mean), except for AER/creat and PER/creat, which are
expressed as geometric mean (antilog 95% CI). CrCb, creatinine clearance; MAP, mean arterial pressure; AER/creat, urinary albumin
excretion rate standardized for urinary creatinine excretion rate; PER/creat, urinary protein excretion rate standardized for urinarycreatinine excretion rate. P values are obtained with paired t tests (within each treatment block).
150.
100.
50.
8)
‘3
a)0)CCs
‘3
Tyvy,
AA�&
-50.
-100.
-150.
Danaparoid Sodium and Proteinuria 459
Table 3a. Individual results: AER/creat
. Danaparoid SodiumPatient R
No. � wk 4 (�) wk 6 (6) wk
Placebo
8 (3) wk 0 wk 4 (�) wk 6 (�) wk 8 (�) wk
1 D 64 83(+29%) 75(+17%) 53(-18%) 78 63(-20%) 77(-l%) 77(-l%)
2 P 133 1l4(-14%) lll(-l7%) 107(-l9%) 90 74(-19%) 138(+52%) l24(+36%)
3 D 250 205(-l8%) 238(-5%) 217(-13%) 280 292(+4%) 223(-20%) 337(+2l%)
4 P 75 78(+4%) 90(+l9%) 77(+3%) 63 87(+37%) 75(+18%) 73(+l5%)
5 P 144 b86(+29%) l29(-ll%) l13(-22%) 96 132(+38%) l36(+42%) ll8(+24%)
6 D 64 33(-49%) 42(-35%) 29(-54%) 39 44(+l4%) 55(+4l%) 47 (+21%)
7 D 52 56(+8%) 43(-l8%) 54(+3%) 60 38(-36%) 43(-28%) 42 (-30%)
8 P 21 l9(-lb%) 22(+4%) 15(-26%) 21 24(+13%) l3(-40%) 20(-6%)
9 D 46 26(-44%) 40(-l2%) 43(-7%) 34 nd 72(+112%) 78(+l27%)
Table 3b. Individual results: PER/creat�’
. Danaparoid SodiumPatient R
No. � wk 4 (�) wk 6 (�) wk
Placebo
8 (t�) wk 0 wk 4 (�) wk 6 (�) wk 8 (�) wk
1 D 90 l31(+46%) l0l(+l3%) 97(+8%) 119 105(-12%) l23(+3%) l23(+3%)
2 P 178 l9l(+8%) l52(-15%) l32(-26%) 122 9l(-26%) l7l(+40%) l63(+33%)
3 D 368 302(-l8%) 347(-6%) 323(-12%) 365 526(+44%) 351 (-4%) 459(+26%)
4 P 127 126(-l%) l30(+2%) l08(-l5%) 97 l30(+35%) llO(+14%) ll2(+l6%)
5 P 211 235(+ll%) l90(-bO%) l40(-34%) 52 195(+277%) l75(+237%) 15l(+l92%)
6 D 86 64(-25%) 62(-27%) 52(-40%) 62 73(+l8%) 80(+29%) 79(+28%)
7 D 72 67(-6%) 63(-l2%) 69(-4%) 83 50(-40%) 58(-29%) 52 (-37%)
8 P 38 34(-ll%) 39(+2%) 27(-29%) 35 43(+2b%) 29(-l9%) 35(-2%)
9 D 70 37(-48%) 58(-l7%) 60(-14%) 60 nd 89(+48%) l24(+105%)
a Note. � values (relative change) for AER/creat and PER/creat were calculated as follows: (y - x/x*lOO%) = 5, where y is the net’
week value for AER/creat or PER/creat and x is the 0 wk value. R (randomization) denotes whether danaparoid sodium (D) or placebo (P)was the first treatment block; AER/creat (and PER/creat), urinary albumin (protein) excretion rate standardized for urinary creatinine
excretion rate; nd, no data.
ing both treatment periods without clinically important side
effects. In two patients, small skin hematomas at the injection
site occurred during treatment with danaparoid sodium. Ac-
cording to the number of returned unused ampoules and the
compliance checklist, the compliance was excellent; only two
patients skipped one injection. The duration of treatment was
42 days (median) for danaparoid sodium (range, 41-47) and 42
days (range, 41-45) for the placebo treatment.
Efficacy Parameters
A significant decline of both albuminuria and proteinuria
was found after treatment with danaparoid sodium compared
with baseline and with the placebo treatment. Figure 1 shows
the percentage reduction of albuminuria for both groups. Com-
pared with baseline, the AER/creatinine at the end of the
treatment period was - I 7% for the danaparoid sodium group
and +23% for the placebo group (95% confidence interval (CI)
ofthe difference -75.9-3.9%, P = 0.03). Even after omitting
the outlier of 126% increase during placebo, a significant
difference was found (P <0.05). The protein excretion rate
standardized for creatinine excretion showed a decrease of
18% in the danaparoid sodium group, whereas an increase of
danaparoid placebo
Figure 1. A scatter diagram showing the percentage difference (�) of
the albumin excretion rate standardized for the urinary creatinine
excretion comparing 8-wk with baseline in both treatment arms. �
values for AER/creat and PER/creat were calculated as follows: (y -
x/x)*l00% = & where y is the 8-wk value for AER/creat and x is the
0-wk value. The difference is significant (P < 0.03).
40% was seen in the placebo group (95% CI of the difference
- 1 15.8-1.0%, P <0.05). Figure 2 shows the mean percentage
change of the urinary protein/creatinine ratios during both
treatment regimens. The difference of the overall change pat-
tern in both treatment groups was highly significant (P =
‘I)>
�w
� 25
0).O 0CCs
U -25
weeks
Figure 2. The percentage change (�) of the protein excretion rate
standardized for urinary creatinine excretion from baseline in bothtreatment arms. The overall difference is P = 0.001 . The relative
change at the respective timepoints 4, 6, and 8 wk in comparison withbaseline was as follows: P = 0.22 (95% CI of the difference -118.3-
29.2%), P = 0.13 (95% CI ofthe difference - 100.1-14.1%), and P =
0.02 (95% CI of the difference - 108.3-9.5%). The bars are standard
errors of the mean. Triangles denote placebo, and squares denote thedanaparoid sodium treatment.
0.001). The relative change at the respective timepoints of 4, 6,
and 8 wk in comparison with baseline was P = 0.41 (95% CI
of the difference -39.6-17.2%), P = 0.15 (95% CI of the
difference -61.7-10.1%), and P = 0.02 (95% CI of the
difference -73.2-6.6%). Similar results were found for the
overall change pattern for urinary albumin/creatinine ratios
(P = 0.002). Especially Figure 2 demonstrates that the effects
on proteinuria (and albuminuria-figure not shown) become
more apparent after 2 months than after the first month. A
small and not significant difference was found comparing the
pre- and post-treatment values for the MAP: after placebo, a
decline of 4.7% was found, and after danaparoid sodium, a
decline of 0.9% was found (P = 0.4). Creatinine clearances did
not differ significantly, either: -5. 1% after danaparoid sodium
and + 16.6% after placebo (P = 0.2). Subanalysis respective-
lyof the use of ACE inhibition and the order of treatment
(danaparoid sodium/placebo or placebo/danaparoid sodium)
was not possible due to low figures
Safety Parameters
No changes in visual acuity occurred during treatment. Fun-
dusphotography did not show hemorrhages, and no progression
of retinopathy was found in any of the patients. Anti-Xa values
were detectable only once in two patients (respectively, 0.12
and 0.10 U/mL; bower limit of detection <0.10 U/mL); this
was not accompanied by any change of coagulation test results
(APTT). No changes occurred for hematological parameters,
and values within each patient during both treatment periods
remained about the same for hemoglobin, leukocytes and
thrombocytes. Liver enzymes (including alkaline phosphatase)
did not change, either.
DiscussionOptimizing the treatment of DM I with the goal of slowing
down the progression of vascular and renal damage has been
the subject of many studies. In the past , intensified insulin
treatment, antihypertensive treatment in general, and especially
ACE inhibition have been shown to slow the progression of
diabetic nephropathy (24-27). We decided to evaluate in a
clinical setting the applicability of proteoglycans as an addi-
tional treatment modality. All of our patients had macroabbu-
minuria, and they had, therefore, passed the point of revers-
ibility of this specific renal disease. The Danish group has
already shown a benefit of LMWH and heparin for microalbu-
minuric patients (19). A previous study with enoxaparin in
macroalbuminuric patients from our unit failed to demonstrate
a statistically significant difference between placebo and
LMWH (20), although a significant decrease in proteinuria was
seen in the treated group when pretreatment values were taken
into consideration. The difference between placebo and
LMWH may not have been found because of the small number
of patients studied and the short duration of the study. In the
study presented here, we observed a clear reduction for the
AER and PER after treatment with danaparoid sodium for 6
wk. Only one woman participated in this study (with a good
response on therapy); we acknowledge more women need to be
studied before our results may be applied to both sexes. Al-
though not clinically or statistically significant, MAP showed a
trend to decline in the placebo group. This might be explained
by regression to the mean. We found no effects on blood
pressure during danaparoid sodium treatment.
The most important result of our study is that the goal to
reduce AER and PER by HS therapy may be feasible. The
favorable chemical and clinical profile of danaparoid sodium in
comparison to heparin and LMWHs made us decide to study
this medication (28). Heparmn-induced thrombocytopenia and
thrombosis is a feared clinical picture with a dismal outcome.
Only danaparoid sodium in comparison to heparin and LM-
WHs is associated with a very low incidence of this compli-
cation (28). Osteoporosis is another drawback associated with
long-term heparin use. Limited experience with LMWHs
showed a more favorable outcome in this respect (29,30).
Heparins and HS both exert anti-inflammatory actions as
well as antiproliferative effects. An excellent short review on
this topic was recently published by Wardle (3 1). Heparin
prevents basic fibroblast growth factor induced proliferation
and may also stop smooth muscle cell proliferation by releas-
ing transforming growth factor �3 from its binding protein
(32,33). It also inhibits the synthesis and release of endothelin-I
by endothelial cells (34). The negative charge at the N position
is thought to be required for the antiproliferative action (35).
Danaparoid sodium is not a LMWH but a heparinoid. It
consists of 84% HS. Only a small fraction (4%-5%) of this HS
is highly sulfated and is considered to be important for the
anti-Xa activity. The fraction of HS with a low affinity for
antithrombin III does not affect coagulation factors Xa and lIa
but contributes substantially to the antithrombotic activity,
probably through an effect on endothelial cells (23). The dose-
related response to danaparoid sodium remains gradual and
linear over a wide range, which may contribute to its safety. It
has a 100% bioavailibility after subcutaneous administration.
Studies in humans have been using heparin or LMWH. We
thought that danaparoid sodium could have a more favorable
460 Journal of the American Society of Nephrology
Danaparoid Sodium and Proteinuria 461
benefit/risk profile in case of long-term prescription in com-
parison to LMWH. The theoretical arguments of a bower sub-
fate content and, hence, less effect on proteinuria were not
validated by our findings. Whether only the 4%-5% high-
affinity HS fraction has been of relevance for the antiprotein-
uric effect or the low sulfated fraction has been of a comple-
mentary benefit has yet to be established. Based on the half-life
time of danaparoid sodium (25 h for the anti-Xa activity), a
4-wk wash-out period was thought-prior to the study-to be
reasonable and long enough. The results and especially the
increase of proteinuria during the placebo period suggest in
retrospect that this increase might, in part, be explained by a
carry-over effect. However, in the Danish study, the LMWH
and the placebo groups also showed 3 months after the study an
increase of albuminuria of 30% and 125% relative change,
respectively (19). For further crossover studies, not only the
drug half-life time, but also an additional lag-time because of
the mediated effects of danaparoid sodium should be taken in
consideration to prevent this putative confounding effect.
Our results are in agreement with previously reported results
of proteoglycans on proteinuria in diabetic nephropathy
(19,20). This short-term study demonstrates, as already seen in
animal models, that proteoglycans can exert a reversible effect
also at a late stage of nephropathy ( 18). Because we have not
taken any renal biopsies to substantiate the level of changes on
histological examinations, we can only hypothesize about the
mechanism of action. As danaparoid sodium is mainly cleared
by the kidneys, both replacement of “faulty” HS molecules in
the OBM as well, as a beneficial effect on smooth muscle cell
and mesangial cell proliferation, could have accounted for the
clinically observed effects. In previous studies using sulfated
glycosaminoglycans, no differences were found for gbomerular
filtration rate, renal plasma flow, and filtration fraction
(19,20,36). This suggests that the antiproteinuric effect of HS
is not related to altered renal hemodynamics.
In conclusion, the once-daily SC administration of 750 an-
ti-Xa u of danaparoid sodium resulted in a significant reduction
of proteinuria in patients with overt diabetic nephropathy.
More clinical studies are needed to confirm and extend our
findings. A dose-finding study should also be performed. It is
obvious that only long-term studies will prove that the reduc-
tion of proteinuria will be associated with a slower decline or
even maintenance of renal function in diabetic nephropathy.
AcknowledgmentsIan Egberts (NV Organon, Oss, the Netherlands) has contributed
with fruitful discussions and provided us with medication and pla-
cebo. We are indebted to Koos Zwinderman (Department of Medical
Statistics, University of Leiden, The Netherlands), who assisted in the
statistical analysis.
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