Current Opinion in Nephrology and Hypertension最新文献

Purpose of review: As the most common primary glomerulonephritis, immunoglobulin A (IgA) nephropathy (IgAN) is an important cause of kidney failure and mortality. Until recently, therapeutic options were limited. Fortunately, there have been numerous recent clinical trials demonstrating efficacy of new therapies in slowing chronic kidney disease (CKD) progression at varying stages of disease.

Recent findings: The TESTING trial has provided high-quality evidence for slowing estimated glomerular filtration rate (eGFR) decline with a reduced-dose glucocorticoid regimen, while demonstrating an improved safety profile. Targeted-release budesonide represents a well tolerated therapy for reducing eGFR decline. Mycophenolate mofetil may reduce CKD progression in some populations, while hydroxychloroquine is efficacious in reducing proteinuria. Sodium-glucose cotransporter (SGLT2) inhibitors and sparsentan are effective therapies for CKD due to IgAN, but should not be used in lieu of disease-modifying immunosuppressive therapy. Many new therapies are approaching readiness for clinical use.

Summary: Numerous therapeutic options now exist and include disease-modifying and nephroprotective drugs. Identifying the right treatment for the right patient is now the clinical challenge and, with new drugs on the horizon, represents the primary unmet research need in this rapidly-developing field.

Purpose of this review: Metabolic acidosis is frequently encountered in patients with chronic kidney disease (CKD), with increasing prevalence as kidney function worsens. Treating electrolyte disturbances is the sine qua non of Nephrologists, and alkali therapy to normalize serum bicarbonate levels and slow progression of kidney disease has been embedded in clinical practice guidelines for decades on the basis of animal models and controversial clinical trials. This review will critically appraise the literature base for this recommendation and determine whether the available evidence supports this common practice, which is a timely endeavor considering the impending demotion of metabolic acidosis treatment from recommendation to practice point in forthcoming KDIGO guidelines.

Recent findings: Earlier, open-label, studies supporting the utility of sodium bicarbonate therapy to slow progression of chronic kidney disease have been challenged by more recent, blinded, studies failing to show benefit on CKD progression. This was further demonstrated in the absence of concomitant sodium administration with the hydrochloric acid binder veverimer, which failed to demonstrate benefit on renal death, end stage kidney disease or 40% reduction in estimated glomerular filtration rate in a large multicenter trial.

Summary: The current body of literature does not support the routine treatment of metabolic acidosis in patients with CKD and the authors agree with the forthcoming KDIGO guidelines to de-emphasize this common practice.

Purpose of review: Identifying patients with risk of developing progressive chronic kidney disease (CKD) early is an important step in improving kidney care. This review discusses four recently developed models, two which predict risk of new onset disease, and two which predict progression earlier in the course of disease.

Recent findings: Several models predicting CKD incidence and progression have been recently developed and externally validated. A connecting theme across these models is the use of data beyond estimated glomerular filtration rate, allowing for greater accuracy and personalization. Two models were developed with stratification by diabetes status, displaying excellent model fit with and without variables like use of diabetes medication and hemoglobin A1C. Another model was designed to be patient facing, not requiring the knowledge of any laboratory values for use. The final model was developed using lab data and machine learning. These models demonstrated high levels of discrimination and calibration in external validation, suggesting suitability for clinical use.

Summary: Models that predict risk of CKD onset and progression have the potential to significantly reduce disease burden, financial cost, and environmental output from CKD through upstream disease prevention and slowed progression. These models should be implemented and evaluated prospectively in primary care settings.