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Significant proteinuria as a predictor of renal prognosis in malignant hypertension patients with thrombotic microangiopathy: a prospective cohort study

Year: 2025

Type: article

Abstract: BACKGROUND: Malignant hypertension (mHTN) is the most severe form of hypertension. Thrombotic microangiopathy (TMA) serves as both a complication of mHTN and a contributor to its progression by exacerbating renal damage. Proteinuria is a common manifestation of mHTN. However, the impact of proteinuria on renal prognosis in mHTN patients with TMA is unclear. METHODS: This observational cohort study included 276 mHTN-associated TMA patients based on renal biopsy from 2008 to 2023. Demographic characteristics, laboratory results, and histopathological findings were recorded and compared between the mild (< 1 g / 24 h) and significant (≥ 1 g / 24 h) proteinuria groups. Propensity score matching (PSM) was used to adjust for baseline differences. Cox regression model was employed to evaluate risk factors associated with renal prognosis. RESULTS: Among the 276 patients included in the study, 185 (67.0%) had significant proteinuria, while 91 (33.0%) had mild proteinuria at baseline. After PSM, 83 pairs of patients with mHTN-associated TMA were matched. Patients with significant proteinuria exhibited lower serum albumin, and higher ratio of global sclerosis compared to patients with mild proteinuria. Moreover, mHTN-associated TMA with significant proteinuria was independently associated with receiving renal replacement therapy (RRT) (adjusted hazard ratio (aHR), 1.30; 95% confidence interval (CI), 1.16-1.46; P < 0.001) compared with mild proteinuria. This association remained significant after PSM (aHR, 1.29; 95% CI, 1.13-1.47; P < 0.001). Furthermore, mHTN-associated TMA patients with significant proteinuria had a lower incidence of renal function recovery with a reduction in creatinine levels than in patients with mild proteinuria in the absence of intensive blood pressure control. CONCLUSION: In mHTN-associated TMA patients, the presence of significant proteinuria serves as a strong predictor of poor renal outcome. CLINICAL TRIAL NUMBER: Not applicable.

Source: BMC Nephrology

DOI: 10.1186/s12882-025-04407-6