Volume 9 Issue 3, March 2013

The aetiology of primary focal segmental glomerulosclerosis has proven elusive. Recent data implicates the soluble urokinase-type plasminogen-activator receptor (suPAR) as the circulating permeability factor in the majority of patients with this condition. These exciting findings may dramatically influence the future diagnosis and management of this often resistant glomerular disease.

Bardoxolone methyl showed promising results in initial studies in patients with type 2 diabetic kidney disease, but a phase III trial was terminated early in October 2012 due to adverse effects and increased mortality. Can adverse findings of analogues of bardoxolone methyl in an animal model explain the human findings?

A new meta-analysis shows a strong association between low levels of preformed donor-specific HLA antibodies (DSAs) detected using sensitive solid-phase assays and an increased risk of renal allograft failure. These findings have important implications for stratifying patients with DSAs for organ allocation and for the use of alloantigen desensitization therapies.

Guidelines are painted with broad strokes and cannot possibly cover complex situations that emerge in the care of people with chronic kidney disease and multiple illnesses. The authors of the recent KDIGO blood pressure guidelines should be congratulated on urging us to individualize therapy especially in situations where the evidence base is thin.

World Kidney Day will be celebrated on March 14 2013, and this year, aims to increase awareness of the global increase in acute kidney injury (AKI). An urgent need exists for a global health strategy to reduce the burden of AKI; efforts focused on preventing AKI should be coupled with early detection, treatment, and follow-up strategies.

According to new data from Hirsch et al., the risk of polyomavirus BK (BKV) viraemia in kidney transplant recipients is increased by high steroid exposure early after transplantation, treatment with tacrolimus rather than ciclosporin A, older donor age and male gender. However, confounding of results due to variations in immunosuppressive drug exposure cannot be excluded.

Cellular regeneration—the repair of portions of the existing nephron after tubular damage—is conserved in all animal species. By contrast, nephron neogenesis is present in lower branches of the animal kingdom, but not in adult mammals. Converging evidence suggests that a renal progenitor system is present in the adult kidney across different stages of evolution. Here, the authors look at renal regeneration from an evolutionary perspective and suggest possible explanations for the differences between animals.

Many noninsulin glucose-lowering agents have pharmokinetic and elimination profiles that preclude their use in patients with reduced renal function. However, several of these drugs can be used safely in patients on dialysis and should be considered by physicians. In this Review, the authors provide a guide to the use of noninsulin hypoglycaemic agents for the management of diabetes in patients receiving dialysis and also discuss the monitoring of glycaemic control in these patients.

Rituximab offers an alternative approach to current immunosuppressive therapies for patients with difficult-to-treat, steroid-dependent nephrotic syndrome. Rituximab therapy has been shown to induce and maintain remission in these patients; however, most data are derived from anecdotal reports or case series. This Review provides an overview of available data on the safety and efficacy of rituximab in the treatment of paediatric and adult patients with nephrotic syndrome.

Alport syndrome is a rare disease caused by mutations in the genes encoding collagen type IV. The underlying disease mechanisms are unknown, but disrupted formation of glomerular basement membranes is thought to have a key role in pathogenesis. In this Review, the authors describe the diagnosis of Alport syndrome, current understanding of underlying pathogenetic mechanisms and treatment of this disease.

Advances in molecular genetics and genomic science are improving our understanding of the molecular basis of nephrotic syndrome. However, the availability of genetic testing in the management of nephrotic syndrome poses unique challenges for clinicians in terms of who to test and how best to use the information obtained. Here, the authors present their collective opinion on the clinical indications for and the utility of genetic testing in monogenic nephrotic syndrome based on the evidence available to date.