The identification of patients with chronic kidney disease (CKD) at risk of progressing to kidney failure (KF) is important for clinical decision-making. Thus, Massy et al. assessed whether urinary peptidome (UP) analysis may help classify patients with CKD and improve KF risk prediction.

• The UP was analyzed using capillary electrophoresis coupled to mass spectrometry in a case-cohort sample of 1000 patients with CKD stage G3 to G5 from the French CKD-Renal Epidemiology and Information Network (REIN) cohort.
• They used unsupervised and supervised machine learning to classify patients into homogenous UP clusters and to predict 3-year KF risk with UP, respectively.
• The predictive performance of UP was compared with the KF risk equation (KFRE), and evaluated in an external cohort of 326 patients.

More than 1000 peptides classified patients into 3 clusters with different CKD severities and etiologies at baseline. Peptides with the highest discriminative power for clustering were fragments of proteins involved in inflammation and fibrosis, highlighting those derived from α-1-antitrypsin, a major acute phase protein with anti-inflammatory and antiapoptotic properties, as the most significant.

Massy et al. then identified a set of 90 urinary peptides that predicted KF with a c-index of 0.83 in the case-cohort and 0.89 in the external cohort, which were close to that estimated with the KFRE . Combination of UP with KFRE variables did not further improve prediction.

This study showed the potential of UP analysis to uncover new pathophysiological CKD progression pathways and to predict KF risk with a performance equal to that of the KFRE.

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