Title of Invention	A COMPOSITION FOR TREATING OR LESSENING THE SEVERITY OF DIABETIC NEPHROPATHY IN A HUMAN PATIENT
Abstract	The invemtion relates to a method of treatment of diabetic nephropathy using mycophenolate mofetil alone or in combination with lisnopril.

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MYCOPHENOLATE MOFETIL IN DIABETIC NEPHROPATHY FIELD OF THE INVENTION The invention relates to use of mycophenolate mofetil alone or in combination with Lisinopril in diabetic nephropathy patients for improvement in proteinuria in patients with diabetic nephropathy. BACKGROUND OF THE INVENTION Diabetes mellitus is one of the common systemic diseases affecting the kidneys. In a third of patients, who have type 1 diabetes for more than 20 years, diabetic nephropathy would have developed. The incidence of nephropathy in type 2 diabetes is uncertain. The involvement of diabetes is essentially glomerular. The primary pathogenic role of hyperglycemia in diabetic renal disease is so well established that diabetic nephropathy is today considered as Hyperglycemic Glomerulopathy. Mortality and morbidity in them is due to cardiovascular disease, probably accelerated by hypertension and hyperlipidemia. Biochemical, hormonal, immunological and rheological factors have been shown to be etiologically important in the pathogenesis of diabetic nephropathy. The biochemical factors implicated include hyperglycemia and glycosylated proteins in blood and basement membrane of the kidneys. Also, there is experimental and clinical evidence to suggesting that recruitment of monocytes into glomeruli may play a role in the pathogenesis of this diabetic complication. Diabetes mellitus accounts for about one-third of all end-stage renal disease. The landmark study by Lewis et al. 1993 demonstrates that, in patients with type 1 diabetes mellitus and diabetic nephropathy, Captopril prevents or delays the progression of renal disease. These findings are generalizable to other Angiotensin Converting Enzyme inhibitors (ACE inhibitors) and to patients with both type 1 and type 2 diabetes regardless of baseline renal function or arterial blood pressure (Ravid et al. 1993, 1996). In addition to preventing diabetic nephropathy, ACE inhibitors also may decrease retinopathy progression in type 1 diabetics (Chaturvedi et al. 1998). Several mechanisms participate in the renal protection afforded by ACE inhibitors. Increased glomerular capillary pressure induces glomerular injury, and ACE inhibitors reduce this parameter both by decreasing arterial blood pressure and by dilating renal efferent arterioles. Since angiotensin II is a growth factor, reductions in the intrarenal levels of angiotensin II may further attenuate mesangial cell growth and matrix production. Mycophenolate mofetil (MMF) is prodrug that is rapidly hydrolyzed to the active drug, mycophenolic acid (MPA), a selective, uncompetitive and reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH), an important enzyme in the de novo pathway of guanine nucleotide synthesis. B and T lymphocytes are highly dependent on this pathway for cell proliferation, while other cell types can use salvage pathways; MPA therefore selectively inhibits lymphocyte proliferation and functions, including antibody formation, cellular adhesion, and migration. The effects of MPA on lymphocytes can be reversed by adding guanosine or deoxyguanosine to the cells (Krensky et al. 2001). MMF ameliorates the renal lesions in several models of experimental glomerular disease. The ability of MMF to suppress not only the immune response, but also smooth cell proliferation makes the drug a candidate for preventing renal fibrosis, as myofibrobalsts share many features with vascular smooth muscle cells. Preliminary results suggest that MMF is effective in several types of glomerulonephritis after conventional therapy had failed (Badid et al. 2001). Two recent studies have evaluated the impact of MMF in patients with IgA nephropathy. Preliminary results from both of these studies were presented at the 2001 Annual Meeting of the American Society of Nephrology (Chen et al. 2001 and Maes et al. 2001). Chen et al, from China, compared the effect of MMF Vs Prednisone in 62 patients. The age of these patients ranged from 9-54 years. Each of the patients had protein excretion rates >2g per day. The dose of the MMF given to the patients varied from 1-1.5g per day whereas a control group received 30-40 mg of Prednisone per day. Fifteen patients in each of the groups had been followed for seventy two weeks. Whereas both groups of patients showed reduction of proteinuria after 3 and 6 months, the decrease in the MMF patients was greater after 6 months. This decrease in proteinuria continued in the MMF group through 72 weeks. Chen et al concluded in this preliminary report that MMF was superior to Prednisone in decreasing proteinuria, protecting renal function and also decreasing blood lipid levels. With most immunosuppressive agents, increasing the degree of immunosuppression increases the likelihood of side effects of immunosuppression, including infection and bone marrow suppression. However, experience from controlled clinical trials in renal transplantation shows that MMF may be an exception to this generalization because the MMF-treated patients were able to achieve a greater degree of immunosuppression yet suffered little increase in the incidence of infection or bone marrow suppression (Dooley et al. 1999). Dooley and his coworkers concluded in their study that MMF is well tolerated and has possible efficacy in controlling major renal manifestation of systemic lupus erythomatosis. In lupus nephritis, these authors found that 0.5 to 1.5 g/d dose of MMF were sufficient. Miller et al. 2000 in their study of mycophenolate mofetil use in resistant membranous nephropathy, used 0.5 to 2.0 g/d dose of MMF. The dose of MMF was titrated according to leukocyte counts and side effects, in most cases because of gastrointestinal symptoms. The most obvious endpoint for treatment failure in patients with diabetic nephropathy is progression to end stage renal disease (ESRD). However, since the period from diagnosis to ESRD in diabetic nephropathy patients with normal renal function at onset may be over 10 years. Only about 30% of diabetics live for 10 years beyond the onset of clinical proteinuria. The degree of diabetes control is a necessary component, but is not linearly related to the development of renal failure. Control of hyperglycemia may become very difficult in nephropathic diabetic. Normalizing the blood pressure at every stage of progressive diabetic renal disease is stressed as an important component of the therapeutic programme. Apart from the control of systemic hypertension, control of intraglomerular hypertension is also considered important in diabetic nephropathy. ACE inhibitors have been shown to lower the intraglomerular hypertension and thus reduce lyperfiltration of diabetic neplnropathy. It is tlierefore, recommended :hat in diabetics with even normal blood pressure, ACE inhibitors be 3iven to lower intraglomerular pressure. Mycophenolate mofetil prevents the development of glomerular njury in experimental diabetes (Utimura et al. 2003). Diabetic rats exhibited marl The present invention discloses the effect of MMF alone or in zombination with Lisinopril in comparison to Lisinopril alone on the progression of diabetic nephropathy. SUMMARY OF THE INVENTION The invention relates to use of MMF alone or MMF in combination /vith Lisinopril for the treatment of diabetic nephropathy. The method of treatment of diabetic nephropathy of the instant nvention is more effective than method of treatment of diabetic lephropathy using lisinopril alone. DETAILED DESCRIPTION OF THE INVENTION The instant invention relates to a method of treatment of diabetic nephropathy using mycophenolate mofetil alone or combination of nycophenolate mofetil with lisinopril. Definitions The term "Efficacy End points" in the present invention is the parameters, which represent the measure of the drugs ability to improve the signs and /or symptoms of the disease. The term "Safety Endpoints" in the present invention is the parameters, which represent any incidence of adverse events and in particular the serious adverse events that may be associated with the use of the drug treatment for diabetic nephropathy. The term "MMF" in the present invention means mycophenolate mofetil. The term "ACE" in the present invention means any drug or molecule that are ACE inhibitors selected from one among and not ■t limited to lisinopril, aptopril, enalapril. The term "Micral test" is a measure of albumin excretion rate in urine. The term "VI" represents the visit no. 1 of the patient during which the subject is screened for eligibility to participate in the drug trial for treatment of diabetic nephropathy. The term "V2" represents the visit no. 2 of the patients during which the said patients are subjected to treatment with either MMF or Lisinopril alone or in combination of both. The term "V3" represents the visit no. 3 of the patients, one month after initialization of the treatment [V2]; during which the said patients are reveiwed and if deemed fit is subjected to further treatment with either MMF or Lisinopril alone or in combination of both. The term "V4" represents the visit no. 4 of the patients, three months after initialization of the treatment [V2]; during which the said patients are reviewed and if deemed fit is subjected to further treatment with either MI^F or Lisinopril alone or in combination of both. The term "V5" represents the visit no. 5 of the patients, six months after initialization of the treatment [V2]; during which the said patients are reviewed and if deemed fit is subjected to further treatment with either MMF or Lisinopril alone or in combination of both. DESIGN OF THE EXPERIMENT The study of the effect of the drugs alone or in combination for the treatment in diabetic nephropathy is designed in the following manner. Sample Size: In this study, a total of 30 patients were planned of which 18 were randomized and subjected to enter into one of the study in which the patients group each received MMF alone or ACEI alone or a combination of both. Efficacy End iioints: Primary : Urine protein/creatinine ratio Secondary : Estimated GFR Safety Endpoints: Adverse Events; Physical Examination; Vital Signs, hematology and clinical biochemistry study Design: Evaluation of the effects of MMF or ACE inhibitors alone or in combination on the status of proteinuria in patients with diabetic nephropathy is an open-labeled, randomized study. The study of has three arms as shown below. 1. treatment with MMF alone 2. treatment with combination of MMF and Lisinopril 3. treatment with Lisinopril alone There were three phases of the study as shown below. Phase 1: Screening Phase (Duration 1 to 4 weeics): 294 patients were screened on their first visit (VI), based on the given inclusion and exclusion criteria to determine if they were eligible for the study and to assess likelihood of compliance with study protocol. Micral test for every patient was done to determine the eligibility. Selection Criteria 1. Inclusion Criteria The inclusion of a patient is based on the following criteria Male diabetic patients; age 18-65 years; micral test positive (albumin excretion rate 20-200 |agm/min); patient must be able to swallow the oral medications to be used in the study; patient must sign an informed consent prior to the study. 2. Exclusion Criteria The exclusion of a subject from the study is based on the following criteria: Female patients of any age; clinical evidence of SLE; well-documented history of Henoch-Schonlein Purpura; clinical evidence of cirrhosis or chronic active liver disease; abnormal laboratory values at the time of study entry; absolute neutrophil count (ANC) 200 |^gm/min; known contraindication or allergy to the administration of MMF or Lisinopril; history of significant gastrointestinal disorder, e.g. severe chronic diarrhea or active peptic ulcer disease; active systemic infection or history of serious infection within one month of entry; known infection with HIV, hepatitis B or hepatitis C; other major organ system disease or malignancy other than skin cancer fully excised more than 5 years prior to entry; current or prior treatment with MMF or azathioprine; current or recent (within 30 days) exposure to any investigational drug. Phase 2: Treatment Phase (6 months): Every patient who qualifies the screening phase is assigned one of the treatment arms. During this phase patients are monitored closely and efficacy and safety parameters are assessed every month. The patients are withdrawn from the study if any of the following are observed: Ingestion of prohibited medication; Serious adverse event; Persistent GI disorder of moderate severity after MMF dose; Hematocrit persistently lower than 25% after MMF dose ; ANC persistently lower than 1500/mm^ after MMF; ANC lower than 1000/mm^ at any time; Administration of live oral vaccine; Patient withdrawal of consent to participate; Patient is moving out of the area of the location of the study center; Interruptions of MMF treatment totaling 28 days or more cumulatively, or any single interruption of more than 21 consecutive days; Inability to tolerate Lisinopril Phase 3: Post-treatment Phase (3 months): During this phase, patients are monitored carefully to determine if they show any changes in estimated GFR or urine protein/creatinine ratios after treatment has been discontinued. Study Products and Dosage: 1. MMF: The dose of MMF was given during the study would be 500 mg twice a day throughout the study. 2. Lisinopril: The starting dose of Lisinopril was given in the study was 5 mg twice a day. In case of hypertensive patients, dose can be titrated upwards based on investigator's discretion, which in turn is based on the patient's "safety end point". 3. MMF + Lisinopril: In the patients who received both the drugs, the dose of MMF was 500 mg twice a day and Lisinopril was 5 mg twice a day. In case of hypertensive patients, dose of Lisinopril can be titrated upwards based on investigator's discretion, which in turn is based on the patient's "safety end point". The Primary Efficacy Endpoints includes the 24 h Urine protein which is measured using the Calorimetric method Pyrogallol Red / SDS liquid stable single reagent. The Urine protein/creatinine ratio is also compared. The Secondary Endpoint includes Estimated GFR, which is calculated using the formula Estimated GFR (mL/min) = [104 - age (in years)] x weight (in kgs) Serum creatinine level (in pmol/L) The following non-limiting examples illustrate the inventors' preferred method for preparing the compounds of the invention. EXAMPLES 18 male patients are selected at visit no.l [VI] with Type 1 and type 2 diabetes for the trial between the age group of 18-65 years who show positive Micral test (albumin excretion rate 20-200 i^gm/min) Example 1 The values of base line lab parameters like 24 h Urine protein and estimated GFR are obtained from the patients in visit no. 2 [V2] prior to treatment with MMF. The values of the parameters in V2 are compared against the values obtained at Visit 3 [V3], which is scheduled 1 month from V2. MMF at the end of 1 month of treatment reduced proteinuria in 67% of the patients. The effect of the treatment on proteinuria is disclosed in the table below. Example 2 The values of base line lab parameters like 24 h Urine protein and estimated GFR are obtained from the patients at V2 prior to treatment with MMF. The values of the parameters in V2 are compared against the values obtained at V3, which is scheduled 3 months from V2 during which patients receive 500 mg of MMF twice daily. MMF treatment at the end of 3 months reduced proteinuria in 67% of the patients. The effect of the treatment on proteinuria is disclosed in the table below. Example 3 The values of base line lab parameters like 24 h Urine and estimated GFR are obtained from the patients at V2 prior to treatment with Lisinopril. The values of the parameters at V2 are compared against the values obtained at V3, which is scheduled 1 month from Ml, during which patients received 5mg of Lisinopril twice daily. Lisinopril treatment at the end of 1 month reduced proteinuria in 42% of the patients. The effect of the treatment on proteinuria is disclosed in the table below. • -1 Example 4 The values of base line lab parameters like 24 h Urine protein and estimated GFR are obtained from the patients at V2 prior to treatment with Lisinopril. The values of the parameters at V2 are compared against the values obtained at V4, which is scheduled 3 month from Ml, during which patients received 5mg of Lisinopril twice daily. Lisinopril treatment at the end of 3 month reduced proteinuria in 40% of the patients. The effect of the treatment on proteinuria is disclosed in the table below. Example 5 The values of base line lab parameters like 24 h Urine and estimated GFR are obtained from the patients at V2 prior to treatment with Lisinopril. The values of the parameters at V2 are compared against the values obtained at V5, which is scheduled 6 month from V2, during which patients received 5mg of Lisinopril twice daily. Lisinopril treatment at the end of 6 month reduced proteinuria in 50% of the patients. The effect of the treatment on proteinuria is disclosed in the table below. Example 6 The values of base line lab parameters like 24 h Urine protein and estimated GFR are obtained from the patients at V2 prior to treatment with the combination of MMF and Lisinopril. The patients were treated with 500 mg of MMF twice daily along with Lisinopril 5 mg twice daily. The values of the parameters in V2 are compared against the values obtained at V3, which is scheduled 1 month from V2. MMF and Lisinopril combination treatment at the end of 1 month of treatment reduced proteinuria in 75% of the patients. The effect of the treatment on proteinuria is disclosed in the table below. Example 7 The values of base line lab parameters like 24 h Urine protein, urine protein/creatinine ratio and estimated GFR are obtained from the patients at V2 prior to treatment with the combination of I^MF and Lisinopril. The patients were treated with 500 mg of MMF twice daily along with Lisinopril 5 mg twice daily. The values of the parameters in V2 are compared against the values obtained at V4, which is scheduled 3 month from V2. MMF and Lisinopril combination treatment at the end of 3 month of treatment reduced proteinuria in 100% of the patients. The effect of the treatment on proteinurea is disclosed in the table below. Example 8 The values of base line lab parameters like 24 h Urine protein, urine protein/creatinine ratio and estimated GFR are obtained from the patients at V2 prior to treatment with the combination of MMF and Lisinopril. The patients were treated with 500 mg of MMF twice daily along with Lisinopril 5 mg twice daily. The values of the parameters in V2 are compared against the values obtained at V5, which is scheduled 6 month from V2. MMF and Lisinopril combination treatment at the end of 6 month of treatment reduced proteinuria in 100% of the patients. The effect of the treatment on proteinuria is disclosed in the table below. We Claim: 1. P Method of treatment of diabetic nephropathy using I Immunosuppressive agents. 2. \ Method of treatment of diabetic nephropathy as in claim 1, / wherein the immunosuppressive agents is used in combination with ACE inhibitors. -N 3. / Method of treatment of diabetic nephropathy as in claim 1, X / wherein the immunosuppressive agents is mycophenolate mofetil, / its salt or pharmaceutically acceptable derivative. 4.1 Method of treatment of diabetic nephropathy as in claim 2, wherein the ACE inhibitor is lisinopril, its salt or pharmaceutically acceptable derivative. 5. Use of mycophenolate mofetil, its salt or pharmaceutically acceptable derivative for the treatment of diabetic nephropathy. 6. Use 0^ mycophenolate mofetil, its salt or pharmaceutically -i^l^"'^ acceptable derivative as in claim 5, in combination with lisinopril, its salt or pharmaceutically acceptable derivative for the treatment of diabetic nephropathy. 7. A combination, formulation, composition or compound containing mycophenolate mofetil, its salt or pharmaceutically acceptable ;• i b > )' derivative and lisinopril, its salt or pharmaceutically acceptable derivative for the treatment of diabetic nephropathy. 8. A method of treatment of diabetic nephropathy using immunosuppressive agente substantially as herein described with reference to the foregoing examples. Uise__oLjI!YCOjghenollate mofetil, its salt or pharmaceutically > acceptable derivative for the treatment of diabetic nephropathy substantially as herein described with reference to the foregoing examples. A combination, formulation, composition or compound containing mycophenolate mofetil, its salt or pharmaceutically acceptable derivative and lisinopril, its salt or pharmaceutically acceptable derivative for the treatment of diabetic nephropathy substantially as herein described with reference to the foregoing examples.

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