Dr. Hogan, MD, is Assistant Professor of Medicine and Clinical Director of the Glomerular Disease Center at the University of Pennsylvania in Philadelphia, PA. His clinical and research interests are in glomerular diseases, paraprotein-mediated kidney diseases, and onconephrology. He has published multiple original research and review articles on these topics.
The first match-up pits two topics against each other that always spark lively discussion during ASN Kidney Week.
Protocol biopsies for lupus nephritis (LN): Pro-biopsy folks tout the use of repeat kidney biopsies in helping to further understand biology and make treatment decisions. Anti-biopsy docs say that we use the same meds for all severe LN cases anyway. But the power of the protocol biopsy lies not in what we can glean from it now, but what we can learn from it in the future. Brad Rovin’s group at Ohio State University is using sophisticated research approaches to use kidney biopsies to understand the biology of each patient’s individual disease (after all, all patients with lupus don’t have the same biology, right?). This is where nephrology should be headed.
Steroids in IgA nephropathy: This topic is like Gonzaga – always there, but just can’t make the big game. The STOP-IGA Trial was meant to resolve the controversy about using steroids in IgA, but I think the study’s limitations left us where we started (i.e. those who believe in using steroids will still use them, and those who don’t believe in using steroids still won’t use them). Protocol biopsy wins, Gonzaga goes home early again.
The late game is an interesting match-up. Beck and Salant‘s discovery of the anti-PLA2R antibody in the majority of patients with “idiopathic membranous nephropathy (MN)” changed how we think about this disease. We now have a sensitive and specific biomarker that helps for the diagnosis of MN. Whereas in most other glomerular diseases we can only dream of making a diagnosis without a kidney biopsy, one could argue that a positive serum anti-PLA2R antibody could obviate the need for a kidney biopsy. But that’s not all! The correlation between antibody titer and disease titer has been revolutionary, allowing for biomarker-driven treatment to the goal of an immunologic remission. This is big time.
Rituximab (RTX) treatment for minimal change disease (MCD) is intriguing. It is emerging as a go-to therapy for patients with steroid-dependent MCD, is generally well-tolerated, and can lead to much-needed durable remissions in patients who have been on the yo-yo of relapse/remission for many years. Its success in these patients also has implications for how rituximab works. Is MCD mediated by a circulating factor secreted by B cells? Is the B cell-T cell interaction disrupted? Is it the direct, stabilizing effect of rituximab on the podocyte? Also, will a cheaper biosimilar RTX be made when its patent expires? RTX for MCD has a good half, but gets blown out in the second half.
The Anti-PLA2R is just too important, too novel.
Explore these concepts in detail with the Glomerulonephritis Region scouting report.
– Guest Post written by Jonathan Hogan
As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.