I’m usually a dialysis person, but was thrilled to leave my comfort zone and attend the Case-Based Approach to Managing Immunosuppression in Glomerular Disease session. What really made an impression on me was the talk by Dr. Jai Radhakrishnan (@jradnephro) from Columbia, who presented a clear and concise discussion of three primary GNs: IgA, Minimal Change, and Membranous.
In IgA nephropathy, Dr. Radhakrishnan highlighted that a spontaneous remission can occur and that, perhaps, some of the ‘treatment successes’ that are seen may in fact have nothing to do with immunosuppression treatment. The key factor in approaching whether and when to treat IgA was sustained albuminuria in the setting of maximal ACEi or ARB use. He highlighted the STOP-IgA Trial, which, somewhat understated, was notable for almost 30% of enrollees to have a spontaneous remission in the six months of the study prior to initiation of immunosuppression. Critically, in the presence of normal GFR, it could be very reasonable to continue conservative treatment with RAS blockade and lipid control beyond the 6 month threshold. The other claim to fame of this part of the talk was his unsolicited quote on NephMadness, during which he proclaimed “I am not a tweetologist.” If only that could be said for leaders in other positions in the US…
Dr. Radhakrishnan next discussed Minimal Change Disease, focusing on those patients who frequently relapsed. Noting the paucity of trial data, for these patients, he viewed rituximab as his go-to options, describing a two-dose course followed by provision of a bottle of urine dipsticks for prompt home proteinuria assessment prior to clinical symptoms. Interestingly, he noted that, even without any further rituximab administration, MCD may never recur, and, that in resource-poor nations, there were reports of long-term success with one-time administration of rituximab. The real take-home point here was that for these individuals with frequent relapses, rituximab could lead to a normal life.
Dr. Radhakrishnan closed with a discussion of Membranous Nephropathy (MN). This is a disease where so much has been learned about pathogenesis in such a short time and we are just now learning how to apply this knowledge. He highlighted the utility of anti-PLA2R antibody staining on initial pathology and, critically, following serial levels of serum anti-PLA2R. Much of this was based on anecdote and small series, but it was compelling, similar to the discussion of IgA Nephropathy. The classic teaching is that MN often will have spontaneous remission. Dr. Radhakrishnan built on this premise, noting that a decline in anti-PLA2R levels could foreshadow a clinically detectable remission by months, allowing nephrologists to watch patients with MN for months to years on conservative therapy, in the setting of fairly stable kidney function, without initiating immunosuppression.
Aside from learning that Dr. Radhakrishnan really didn’t understand NephMadness (future Blue Ribbon Panel member perhaps??) or Twitter, and particularly in the context of the other talks in the session by Dr. Samir Parikh and Dr. Rupali Avasare highlighting risks associated with immunosuppression, the take-home from this session was that watchful waiting may be the best strategy in many kidney diseases, reserving immunotherapy for times of critical need.
– Post prepared by Daniel Weiner, AJKD Policy Forum Editor. Follow him @dwein003.