There is a nice debate in this months JASN between Rifkin and Hsu about whether AKI leads to CKD. This is timely as the recent KDIGO guidelines have suggested that AKI be considered a risk factor for CKD - the logical implication of this being that all patients with AKI (including those who have completely 'recovered') be monitored for life for CKD. Rifkin and colleagues pint out that whilst its certainly biologically plausible for AKI to lead to CKD, there may be common risk factors of kidney injury that independently predispose to both AKI or CKD and furthermore its entirely plausible that CKD itself may predispose to AKI. In many ways I find the argument a bit sterile... have we not known for many years that if the AKI 'hit' is severe enough then people may be left with residual CKD whilst those wilth mild AKI appear to recover fully. As Rifkin and colleagues point out more than 500,000 AKI events occur in in the USA every year and the the vast majority recover without any significant longterm complication. The idea that all these patients need lifelong monitoring in case they get CKD is neither economically viable nor based on sound clinical judgement. An obviously pragmatic approach would be to monitor those who had severe or dialysis dependent AKI for a few years to see if CKD develops. In contrast its hard to believe that those whos have mild AKI that resolves quickly (with no comorbidity) will benefit from lifelong screening for CKD. Clearly longterm observational studies if AKI may help resolve this debate but in the meantime I suspect most nephrologist will be able to get buy just using clinical common sense....
It is 30 years since we put forward the hypothesis that lipids were nephrotoxic and that dyslipidemia contributed to progressive CKD.
30 years on, a new era of APOL1-associated CKD suggest that a link may indeed exist between genetic mutations affecting HDL cholesterol concentrations and the pathogenesis of nephropathies as variants of ApoL1 proteins associate with circulating HDL.
The association between apoliporotein L1 (APOL1) gene mutations and CKD is becoming increasingly evident with APOL1 variants considered initiating factors for most hypertension-attributed nephropathies in African Americans (AA) as well as a spectrum of renal disease in hispanic as well as European Americans. Variations in APOL1 appears to be strongly associated with kidney disease historically labelled as hypertensive arterioslosclerosis in AA.
It is intriguing to realise that APLO1, a disease associated gene, has persisted in AA. However, it is of interest to realise that one copy of the APOL1 G1 or G2 nephropathy risk variant confers protection from the deadly African Sleeping Sickness while not necessarily being associated with a nephropathy as for the latter to develop a second hit is often necessary. HIV infection is one of many such second hits initating APOL1-associated nephropathy in susceptible individuals with one or two gene variants.
Of interest, individuals with two APLO1 gene variants develop ESRD at a younger age than those with zero or one gene variants. A single gene variant, G1 but not G2, also leads to an earlier onset of ESRD albeit later than those with G1 and G2 variants. This may be due to the fact that tghose with 2 APLO1 gene variants progress to ESRD at a faster rate.
It is likely that the MYH9-APOL1 gene region on chromosome 22q contains additional risk loci that may be difficult to detect due to the high degrees of linkage desiquilibrium.
Clearly, a new era of understanding non diabetic glomerulosclerosis with APLO1-MYH9 genetic mutations providing suceptibility and second hits/modifiers genes leading to initiation and progression of CKD.
Perhaps, after all, we were right when in 1982, we suggested that lipo- and apo- lipoprotein abnormalities may underly the initiation and progression of CKD.
Moorhead JF, , , M.
Lipid nephrotoxicity in chronic progressive glomerular and tubulo-interstitial disease.
Lancet. 1982 Dec 11;2(8311):1309-11.
Kanji et al. genetic variations of APOOL1 associated with younger age at hemodialysis initation. JASN 2011; 22:2091-97.
Tzur et al. APOL1 allelic variants are associated with lower age at dialysis initiation...
NDT 2012; 27:1498-1505.
Paweena Susantitaphong, MD,1,2,3 Ioannis Koulouridis, MD,1,2 Ethan M. Balk, MD, MPH,2,4 Nicolaos E. Madias, MD,1,2 and Bertrand L. Jaber, MD, MS1,2
Background: Increased left ventricular (LV) mass is a risk factor for cardiovascular mortality in patients with chronic kidney failure. More frequent or extended hemodialysis (HD) has been hypothesized to have a beneficial effect on LV mass.
Study Design: Meta-analysis.
Setting & Population: MEDLINE literature search (inception to April 2011), Cochrane Central Register of Controlled Trials and ClinicalTrials.gov using the search terms “short daily HD,” “daily HD,” “quotidian HD,” “frequent HD,” “intensive HD,” “nocturnal HD,” and “home HD.”
Selection Criteria for Studies: Single-arm cohort studies (with pre- and post-study evaluations) and trials examining the effect of frequent or extended HD on cardiac morphology and function and blood pressure parameters. Studies of hemofiltration, hemodiafiltration, and peritoneal dialysis were excluded.
Intervention: Frequent (2-8 hours,
Survival in Daily Home Hemodialysis and Matched Thrice-Weekly In-Center Hemodialysis Patients
Eric D. Weinhandl,* Jiannong Liu,* David T. Gilbertson,* Thomas J. Arneson,* and Allan J. Collins*†
*Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; and †Department of Medicine, University of Minnesota, Minneapolis, Minnesota
Frequent hemodialysis improves cardiovascular surrogates and quality-of-life indicators, but its effect on survival remains unclear. We used a matched-cohort design to assess relative mortality in daily home hemodialysis and thrice-weekly in-center hemodialysis patients between 2005 and 2008. We matched 1873 home hemodialysis patients with 9365 in-center patients (i.e., 1:5 ratio) selected from the prevalent population in the US Renal Data System database. Matching variables included first date of follow-up, demographic characteristics, and measures of disease severity. The cumulative incidence of death was 19.2% and 21.7% in the home hemodialysis and in-center patients, respectively. In the intention-to-treat analysis, home hemodialysis associated with a 13% lower risk for all-cause mortality than in-center hemo- dialysis (hazard ratio [HR], 0.87; 95% confidence interval [95% CI], 0.78–0.97). Cause-specific mortality HRs were 0.92 (95% CI, 0.78–1.09) for cardiovascular disease, 1.13 (95% CI, 0.84–1.53) for infection, 0.63 (95% CI, 0.41–0.95) for cachexia/dialysis withdrawal, 1.06 (95% CI, 0.81–1.37) for other specified cause, and 0.59 (95% CI, 0.44–0.79) for unknown cause. Findings were similar using as-treated analyses. We did not detect statistically significant evidence of heterogeneity of treatment effects in subgroup analyses. In summary, these data suggest that relative to thrice-weekly in-center hemodialysis, daily home hemodialysis asso- ciates with modest improvements in survival. Continued surveillance should strengthen inference about causes of mortality and determine whether treatment effects are homogeneous throughout the dialysis population.
J Am Soc Nephrol 23: 895–904, 2012. doi: 10.1681/ASN.2011080761
Once more, these authors, like those before them reporting on the Frequent HD Network, fail to consider the fact that perhaps the Frequent HD group had more HD (in terms of duration/hours per week and in terms of higher weekly KT/V).
Once more, the authors do not seem to distinguishe between Frequent HD and Longer HD.
The Tassin group implied 20 years ago that longer hours on HD per week was good for HD patients, now the whole bandwagon of Frequent HD is rolling without considering that the adequate control group should be:
Group A: Frequent HD
Group B: Thrice weekly HD, BUT with same duration of HD per week copmpared to group A.
That is the propensity analysis that these studies should undertake; comparing hours on HD not how frequent people get on the machine...
Then the modest difference will be even more modest...non-existent!
Even the editorial by David Wheeler doesnt seem to get the point of longer hours versus More Frequent; the FHN study was all about longer hours and better KT/V not too mention better ultrafiltration.
What do we expect the average reader to conclude if even the editorial board doesnt get it!
Rituximab, a chimeric monoclonal anti-CD20 antibody, has now been extensively used in the management of autoimmune diseases including SLE and lupus nephritis as well as AASV (ANCA associated systemic vasculitis).
Concern has been expressed about the association of immunosuppressants, including Rituximab, and the increased risk of Progressive multifocal leukoencephalopathy (PML). The signal and association with Rituximab is of concern and warrants vigilance.
Whilst rare, such an association may be overlooked when considering teh RISK:BENEFIT of rituximab in autoimmune renal disease. However, the devastating nature of PML warrants careful follow-up and vigilance. This, all the more, since the benefit of Rituximab in conditions such as LN (LUNAR study) and ANCA associated vasculitis (RAVE INT & RITUXIVAS studies) is not superior to current therapies!
A recent article in the NEJM, this month, also shows an increased risk of PML with another monoclonal antibody Natalizumab (anti-integrin a4), with increased risk in those who have a positive status in respect to anti-JC virus antibodies, prior use of immunosuppression and duration of treatment.
Perhaps, we should screen the patients we treat willi nilly with Rituximab.. for anti-JC (John Cunningham) antibodies?!
Perhaps, we should use Rituximab less often when evidence supports its indication!?
Once I have had a chance to digest the KDIGO guidelines I will post some thoughts. I note there has been much interest on the KDIGO guidelines on this site. A few things caught my eye - like the suggestion for fish oils in IgA nephropathy. This is based on data by Donadio and colleagues showing a beneficial effect. This has never been reproduced anywhere else and the control group in that study did extraordinarily badly - around 40% ended up on RRT. KDIGO not unreasonably suggest that fish oils are relatively safe and therefore make a 2D recommendation about their use.
In fact 36% of all the statements in the glomerulonephritis guidelines are 2D. And to remind ourselves what does 2D mean? Well '2' is a suggestion and '1' is a recommendation. D means that the quality of evidence that the suggestion is made is ' very low - the estimate of the effect is very uncertain and often will be far from the truth' - to me 2D sounds a lot like opinion and theres nothing wrong with opinion but we need to recognise it as opinion and not fact. If we are going to get the most out of guidelines we need to learn how to read them or perhaps just have guidelines about things for which there is good evidence.
ERA-EDTA Congress update:
Searching for molecular mediators
N-acetyl-D-mannosamine could represent a new non immunosuppressive therapeutic agent in the treatment of minimal change nephropathy.
Minimal Change Disease (MCD), Despite being nearly a century old disease, the first molecular mediator behind the structural and functional changes in MCD was only recently discovered. Angiopoietin- like-4 (Angptl4), a glycoprotein secreted from podocytes in large amounts, is now shown to mediate most of the above mentioned characteristic features of MCD. This upregulation in podocytes is glucocorticoid sensitive, and declines with glucocortcoid treatment. it was shown that Angptl4 secreted from podocytes binds to the GBM and induces albuminuria even before the development of foot process effacement.
A precursor of sialic acid, N-acetyl-D-mannosamine (Man- NAc), leads to improved sialylation of podocyte-secreted Angptl4 and significantly reduced proteinuria. ManNAc is relatively non-toxic, and could represent a new non-immunosuppressive therapeutic agent in the treatment of MCD, if shown to be effective in future clinical trials. It is the first potential drug for MCD that primarily affects protein structure, and could be used alone or synergistically with glucocorticoids, that work at least partly by reducing Angptl4 gene upregulation in podocytes.
Treatment with ManNAc improves other parameters of nephrotic syndrome in PAN rats and also reduces proteinuria in Zucker diabetic fatty rats. One important characteristic of the podocyte that favors the further development of ManNAc as a novel therapeutic agent for nephrotic syndrome is its inability to divide. Since ManNAc crosses cell membranes easily and is also rapidly excreted in the urine after an oral or parenteral dose, it is most likely to accumulate in a non-dividing cell like the podocyte even at small doses without significant systemic effects in other organs composed primarily of dividing cells.
In summary, the discovery of Angptl4 may lead the way to future therapeutic approaches for MCD.
Adam from Paris for GKA 2010
The Theme of this 1st Episode:
Back to Old drugs: Aza, MTx, Hydroxychlorquene.
Less Corticosteroids still do the same action with less S/Es.
Cr Nadir is earlier than Albumin one.
Date: Thursday May 24th 2012
08:30 - 12:30 CME Courses
Rheumatology for nephrologists 46
Peritoneal Dialysis Workshop 47
Title: Rheumatology for nephrologists
Chair: Hans-Joachim Anders, Munich, Germany
David Jayne, Cambridge, UK
i. Welcome and introduction
Hans-Joachim Anders, Munich, Germany
David Jayne, Cambridge, UK
ii. Joint pain in CKD patients: When do we need a joint aspirate?
Hendrik Schulze-Koops, Munich, Germany
1) Sodiumaurate Crystals in Gout is different that those of CPPD crystals in Pseudo gout which may occur in the dialysis population.
2) The Take Home message in unclear monoarthrits; Do Not Wait; and do Aspirate; however;
3) Synovial fluid aspirate is a sterile procedure; however; the risk of complication by sepsis is 1/10,000; which cost a famous German athelet his career by causing septic arthritis for a procedure which is considered in his case may not be justified.
iii. Proteinuria in the patient with arthritis
Volker Vielhauer, Munich, Germany
4) Proteinuria in patients with arthritis include these following 5 main Topics: either Association, Complication, Manifestation, Toxicity and the fifth and the Last but not the least is Co-morbidity.
5) This need Reply: A 34 yrs old male diagnosed as Behcet and was on CsA and CS. Developed proteinuria 2.8 g/24hrs, Cr 88um/L, with Dysmorphic RBCs, Hence referred to the Nephrologist; with a Bx showed IgA in A Behcet Disease with eGFR 60 ml, with no Cresents and no Fibrosis. How to manage? Opinions so to tell you what happen and what they did?
6) Assoicated Renal Disease in Behcet include mainly Amyloidosis 69/156, and GN in 51/152 cases. IgA deposition was found in 22% of GN with Behcet.
7) Associated Renal Disease in RA include: Mesangial GN 40/110, Renal Amyloidosis 33/110 and MN 19/110 cases.
8) The 2012 “standard of care” in lupus nephritis – referral,
drugs and monitoring
Frédéric A. Houssiau, Brussels, Belgium
8) LN is a very heterogenous disease which varies from single shot, or relapsing 1/3 or refractory 1/5 of the cases.
9) Poor prognostic factors include many; but on the top of the lists are Race (AA), non-observance to Rx, Absence of primary response to IS.
10) Poor prognostic factors in the pathology; beyond Roman numerals include fibrinoid necrosis, partial cresents and circumferential cresents.
11) Renal Bx is not a routine procedure in all SLE patients. However; Low C3, High Anti-DNA, or renal involvements include Pr > 0.5 g/24hrs and/or Active sediment are red flagged.
12) You may need Renal Bx so as not to miss APL-related Disease.
13) Which LN patients should be immunosuppressed? Class I, II NO ---, III & IV (both have Endo/extra capillary cellularity and sub-endo ID: YES ---, V in Selected Cases. However; wait for
my 2nd Episode from the EDTA concerning ISN/RPS 2003 Classification for more Info and critic by Ian Roberts.
14) LN: Towards no Steroid regimen? By Imperial College of Kidney and Tx Institute in London UK; by Liz Lighstone et al. Giving on Day 1 and 15th : 500 mg MPS + 1g RTx. Then only use MMF with no steroids. Claiming optimal renal protection.
15) Euro Lupus Nephritis Trial showed LD is equivalent to HD of CYP for induction in LN.
16) The cost of MMF is more than 10 times that of CYP for induction of Rx in LN.
17) Both AZA and MMF have similar effect as maintenance Rx for LN as proved by two trials ALMS (David Wafsy; especially if the two arms were induction with IV CYP) and MAINTAIN.
18) Never forget Plaquanil (Hydrochlorequene) in LN not only in SLE. Nephrologists are reluctant to consider it.
19) This need Reply: A Pregnant Lady with Acute flare of SLE; which IS Rx you recommend? Either with or without LN? and Do you recommend Abortion to save the mother from being ESRD or more complication?
v. Non-renal flares in lupus nephritis patients – new options
Falk Hiepe, Berlin, Germany
20) Bortezomib can cause clinical improvement in severe and refractoy SLE. This proteasome inhibition markedly reduced plasmablasts and plasma cells from the peripheral blood and bone marrow.
David Jayne, Cambridge, UK
viii. ANCA-associated vasculitis - an update on therapeutic
Alan Salama, London, UK
Wait for my 2nd Episode of the Pathology.
The Theme is:
New Pathological Dx with still invalid clinical Significance.
Recent pathological classification of LN 2003 are more confusing than older one and may be wrong.
Criteriae necessary for Dx may not be necessary anymore. (ABMR with C4d –ve).
Wait for my 3rd Episode of the Opening Cermony and Pioneers in European Nephrology .
The Theme is:
There are two "REFRAINS" in the opening Cermony: Continuity and Memory.
Modesty and The Patient is what Kept the Pioneers so Pioneers.
Just as we thought the ONTARGET trial ended all speculation about dual blockade with ACEI and ARB being beneficial, another study reported by a Spanish group showed once again that there is no benefit from dual blockade.