Blog entry by Meguid El Nahas
I have been practicing Medicine and Nephrology for 40 years.
It occured to me that true and major breakthroughs in the management of CKD have been few and far between during these 40-50 years.
In fact, when I started practicing Nephrology and until recently CKD meant: Glomerulonephritis, Pyelonephritis, Reflux nephropathy and Dysplastic Kidney Disease (later called CAKUT), Hypertensive nephrosclewrosis, diabetic nephropathy and PKD (ADPKD).
CKD in the community, with its "epidemic" and all that is the brainchild of KDOQI and KDIGO CKD definitions and classifications that have created a monster out of the decline in kidney function in the over 50 and 60 years...This I will not comment upon here as I have already on many occasions only to dismiss this community CKD (cCKD) and all its ills as the takeover by epidemiologists (rather biostatisticians) and the ones I call "Spreadsheet Nephrologists" of our beautiful profession and specialty...
Back to true Nephrology, and true CKD (previously called Chronic renal failure [CRF]), no biostatistians or epidemiologists needed to tell us that its incidence and prevalence have somewhat increased due to ageing and the associated increase in hypertension and DM - related CKD. Also, more and more elderly present with atherosclerotic and ischemic nephropathies.
But my point here is:
40 years on, has there been any major therapeutic breakthrough in the management of true referred CKD (rCKD)?
My answer is NO:
1. When I started we had a range of anti-hypertensive agents including diuretics and beta-blockers. They treat hypertension effectively with a few other classes of agents including RAAS inhibitors. What matters is the BP control regardless of the agent or class of agents used.
2. For GN primary or secondary, we had immunosuppression with steroids +/- azathioprine/cyclophosphamide. Steroids and Azathioprine/cyclophosphamide remain the cornerstone of the management of GN.
3. For Reflux nephropathy/Pyelonephritis, we had antibiotics prophylactically or otherwise, we still have them, although the clever bacteria we treat or trying to prevent have learned to become more resistant...
3. For ADPKD, still the same treatment, early diagnosis and treatment of hypertension.
4. For HT nephrosclerosis, control hypertension and nil else...
5. For DN, control hypertension and not much more...
So little therapeutic advances that proved superior to those we used 40 years ago...in spite of almost 40-50 years on unabated research and promises to slow CKD progression:
Anti-platelets, anticoagulants, prostaglandins manipulations, nitric oxide manipulations, cytokines, chemokines and growth factors antagonsists, not to mention a number of anti-fibrotic strategies including pirfenidone, collagen synthesis and deposition inhibition etc...and of course TGF-beta1 remains the most fibrogenic of growth factors...and we still have not managed to translate that knowledge (20 years old by now) to the bedside...???!!!
Very disappointing...and worth questioning whether the R&D as well as translation strategies we are relying upon to discover new and more effective therapies to slow CKD progression are effective or at least cost-effective?
May be thats why Nephrologists started to look elsewhere, came up with a new definition of CKD, created new detection tools (eGFR formulas), teamed up with biostatisticians, screened everybody, generated a "CKD Epidemic" to give themselves a new impetus and generate more attention to their dormant specialty...?!