The KDIGO guideline for glomerulonephritis is designed to assist health-care providers in treating patients with glomerular diseases. A guideline is not a set of rules but is intended to allow the ...practitioner to make an informed decision based on the available evidence. Due to its general nature and the variability of strength of the available studies, it is often difficult to directly apply a guideline to the care of an individual patient. This commonly relates to the limited generalizability of the evidence, i.e., does not cover every clinical scenario. To underscore this point, we have introduced within the context of the glomerulonephritis guideline cases with specific features to illustrate the constant need for clinical judgment. These vignettes are intended to demonstrate how the best treatment plans should be individualized and take into account patient preference and clinical acumen, as well as the best available evidence.
Minimal change disease (MCD) is the etiology of 10%-25% of cases of nephrotic syndrome in adults. The mainstay of treatment for adult MCD, oral glucocorticoids, is based on two randomized controlled ...trials and extensive observational data in adults, and this treatment leads to remission in over 80% of cases. Relapses are common, and some patients become steroid-resistant (SR), steroid-dependent (SD), or frequently relapsing (FR). The data guiding the treatment of these patients are limited. Here, we review MCD in adults with particular focus on the evidence for immunosuppressive therapy in these patients.
In the past, most cases of bacterial infection–related glomerulonephritis (IRGN) occurred in children following streptococcal upper respiratory tract or skin infections and were called postinfectious ...GN. Over the past 3 decades, there has been an important shift in epidemiology, bacteriology, and outcome of IRGN. A significant percentage of cases now target adults, particularly the elderly or immunocompromised. Because adult infections are often ongoing at the time of diagnosis, the term IRGN appears more appropriate. The sites of infection in adult IRGN are more heterogeneous than in children, and include the upper respiratory tract, skin, lung, heart, urinary tract, teeth/oral mucosa, and bone. In adults, the disease is more likely to be secondary to non-streptococcal infections, particularly staphylococcal infection. In contrast to the favorable course in children, a significant proportion of adults with IRGN, especially the elderly and diabetics, do not recover renal function. Whereas the pathogenesis of post-streptococcal glomerulonephritis has been studied extensively, leading to the identification of two candidate nephritogenic streptococcal antigens, glyceraldehyde-3-phosphate dehydrogenase and pyrogenic exotoxin B, few investigations have focused on IRGN caused by other bacteria. This review will address the current status of sporadic bacterial IRGN in adults.
A multidisciplinary approach, including pharmacist interventions, has improved clinical outcomes and reduced economic costs in chronic disease management. To our knowledge, this is the first study to ...describe the incorporation of pharmacist‐driven medication management with partnering nephrologists while capitalizing on technology to improve outcomes in a Chronic kidney disease (CKD) population. The authors created a collaborative drug therapy management agreement to enhance medication management for hypertension and diabetes mellitus. Our metrics aligned with the Healthcare Effectiveness Data and Information Set (HEDIS) measures. Most referrals to the program met the HEDIS definition of suboptimal disease control (Diabetes: 19/25 and Hypertension: 45/70). In patients with multiple pharmacy visits, achievement of diabetes targets increased from 23% to 67% and hypertension from 29% to 58%. Those who used technology tools were more likely to reach goals. The positive impact of a pharmacist‐physician collaboration and utilization of technology tools present an opportunity to improve care for CKD patients.
The mechanism of edema formation in the nephrotic syndrome has long been a source of controversy. In this review, through the construct of Starling's forces, we examine the roles of albumin, ...intravascular volume, and neurohormones on edema formation and highlight the evolving literature on the role of primary sodium absorption in edema formation. We propose that a unifying mechanism of sodium retention is present in the nephrotic syndrome regardless of intravascular volume status and is due to the activation of epithelial sodium channel by serine proteases in the glomerular filtrate of nephrotic patients. Finally, we assert that mechanisms in addition to sodium retention are likely operant in the formation of nephrotic edema.
Abstract Background Hyponatremia is the most common electrolyte abnormality in hospitalized patients and is associated with adverse outcomes, but its prevalence and significance in the general US ...population is unknown. Our aims were to determine the prevalence of hyponatremia and its association with mortality in the population. Methods We performed a population-based, cross-sectional study of 14,697 adults aged ≥18 years who participated in the nationally representative National Health and Nutrition Examination Survey for 1999-2004. By using measurements of serum sodium corrected for dilutional effect of hyperglycemia, we determined the association of hyponatremia with patient characteristics, comorbidities, and prescription medications, and performed unadjusted and adjusted Cox proportional hazards regression to find the association of hyponatremia with all-cause mortality. Results We provide the first estimate of the prevalence of hyponatremia in the US population, which in our weighted analysis was 1.72%. Prevalence of hyponatremia was significantly higher in women (2.09%, P = .004) and increased with age. Hyponatremia was more common in subjects with hypertension, diabetes, coronary artery disease, stroke, chronic obstructive pulmonary disease, cancer, and psychiatric disorders, and less common in those with no comorbidities (1.04%, P < .001). There was a significant risk of death associated with hyponatremia in unadjusted (hazard ratio HR, 3.61; P < .001) and adjusted Cox models controlling for demographics, smoking, comorbidities, and insurance status (HR, 2.43; P < .001). There was a U-shaped relationship between serum sodium and HR for mortality. Conclusions Our findings suggest that hyponatremia is a predictor of mortality in the general population independently of age, gender, and comorbid conditions.
Renal biopsies performed in diabetic patients are increasing in number and complexity. This study sought to determine the usefulness of renal biopsy in patients with diabetes and the predictability ...of diagnosing diabetic nephropathy (DN) versus nondiabetic renal disease (NDRD) from clinical and laboratory data.
To assess modern trends, a retrospective study was performed of clinical-pathologic findings in all patients with diabetes who had a biopsy in 2011. Among 2642 native kidney biopsies, 620 (23.5%) were from patients with diabetes.
The cohort included 371 men (60.7%) aged a median (interquartile range) 62 years (52-69) with 10-year (5-15) duration of diabetes mellitus (DM). Median serum creatinine was 2.5 mg/dl (1.6-4.4), and 52% of patients had stage 4-5 CKD. On biopsy, 37% of patients had DN alone, 36% had NDRD alone, and 27% had DN plus NDRD. In NDRD alone, FSGS (22%), hypertensive nephrosclerosis (18%), acute tubular necrosis (ATN) (17%), IgA nephropathy (11%), membranous GN (8%), and pauci-immune GN (7%) comprised 80% of diagnoses, compared with ATN (43%), hypertensive nephrosclerosis (19%), FSGS (13%), and IgA nephropathy (7%) for DN plus NDRD. In multivariate analyses, longer duration of DM was associated with a greater likelihood of DN and a lower likelihood of NDRD: each added year of DM reduced the odds of NDRD by 5% (odds ratio, 0.95; 95% confidence interval, 0.91 to 0.98; P=0.004). DM duration ≥ 12 years was the best predictor (58% sensitivity, 73% specificity) of DN alone.
Approximately one-quarter of all renal biopsies are performed in patients with DM. Judicious use of renal biopsy has uncovered NDRD alone or superimposed on DN in the majority of such biopsies. ATN is emerging as an important category of NDRD, which has not been reported previously.
Pathologic Classification of Diabetic Nephropathy COHEN TERVAERT, Thijs W; MOOYAART, Antien L; JOH, Kensuke ...
Journal of the American Society of Nephrology,
04/2010, Letnik:
21, Številka:
4
Journal Article
Recenzirano
Although pathologic classifications exist for several renal diseases, including IgA nephropathy, focal segmental glomerulosclerosis, and lupus nephritis, a uniform classification for diabetic ...nephropathy is lacking. Our aim, commissioned by the Research Committee of the Renal Pathology Society, was to develop a consensus classification combining type1 and type 2 diabetic nephropathies. Such a classification should discriminate lesions by various degrees of severity that would be easy to use internationally in clinical practice. We divide diabetic nephropathy into four hierarchical glomerular lesions with a separate evaluation for degrees of interstitial and vascular involvement. Biopsies diagnosed as diabetic nephropathy are classified as follows: Class I, glomerular basement membrane thickening: isolated glomerular basement membrane thickening and only mild, nonspecific changes by light microscopy that do not meet the criteria of classes II through IV. Class II, mesangial expansion, mild (IIa) or severe (IIb): glomeruli classified as mild or severe mesangial expansion but without nodular sclerosis (Kimmelstiel-Wilson lesions) or global glomerulosclerosis in more than 50% of glomeruli. Class III, nodular sclerosis (Kimmelstiel-Wilson lesions): at least one glomerulus with nodular increase in mesangial matrix (Kimmelstiel-Wilson) without changes described in class IV. Class IV, advanced diabetic glomerulosclerosis: more than 50% global glomerulosclerosis with other clinical or pathologic evidence that sclerosis is attributable to diabetic nephropathy. A good interobserver reproducibility for the four classes of DN was shown (intraclass correlation coefficient = 0.84) in a test of this classification.
The principle defect in dense deposit disease and C3 glomerulonephritis is hyperactivity of the alternative complement pathway. Eculizumab, a monoclonal antibody that binds to C5 to prevent formation ...of the membrane attack complex, may prove beneficial.
In this open-label, proof of concept efficacy and safety study, six subjects with dense deposit disease or C3 glomerulonephritis were treated with eculizumab every other week for 1 year. All had proteinuria >1 g/d and/or AKI at enrollment. Subjects underwent biopsy before enrollment and repeat biopsy at the 1-year mark.
The subjects included three patients with dense deposit disease (including one patient with recurrent dense deposit disease in allograft) and three patients with C3 glomerulonephritis (including two patients with recurrent C3 glomerulonephritis in allograft). Genetic and complement function testing revealed a mutation in CFH and MCP in one subject each, C3 nephritic factor in three subjects, and elevated levels of serum membrane attack complex in three subjects. After 12 months, two subjects showed significantly reduced serum creatinine, one subject achieved marked reduction in proteinuria, and one subject had stable laboratory parameters but histopathologic improvements. Elevated serum membrane attack complex levels normalized on therapy and paralleled improvements in creatinine and proteinuria.
Clinical and histopathologic data suggest a response to eculizumab in some but not all subjects with dense deposit disease and C3 glomerulonephritis. Elevation of serum membrane attack complex before treatment may predict response. Additional research is needed to define the subgroup of dense deposit disease/C3 glomerulonephritis patients in whom eculizumab therapy can be considered.
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