The start of 2012 is a good time to look back on the previous year to see the current state of nephrology. What have been the important findings that occurred in the past year, and what do we have to look forward to in the year ahead?
Our understanding of glomerular disease has increased with several ground-breaking studies. Recently, high circulating levels of soluble urokinase plasminogen activator receptor were found by Wei and colleagues to be associated with focal segmental glomerulosclerosis and its recurrence after transplantation. This protein binds to beta 3 integrin, which is highly expressed in podocytes.1
These findings were similar to studies in membranous glomerulopathy, showing that auto-antibodies to M-type phospholipase A2 receptor (PLA2R)—which is expressed in glomerular podocytes—are associated with recurrent membranous nephropathy. Additional studies this year should help us to understand the clinical impact of these findings. It would be ideal to have a way to monitor disease in both of these conditions. The clinical application of these findings appears to be the next step.
More and more genetic causes of kidney disease are being identified. Mutations were identified in the gene encoding nonmuscle class 1 myosin (MYO1E) as a cause of childhood-onset, glucocorticoid resistant FSGS.2 In addition, further studies confirmed the importance of the apo-lipoprotein 1 (APOL-1) gene as a primary cause of the increased risk of kidney failure in African-Americans.3
These studies have shown that small changes in this gene helped to prevent sleeping sickness in Africans, but these changes also increase the risk of HIV nephropathy and other forms of kidney disease in African Americans. It is still unclear how we will use this information both for screening and as a stepping stone for both the treatment of both trypanosomiasis and kidney disease.
In dialysis, there has been a swing away from early, asymptomatic initiation of dialysis to a more conservative approach.
Ironically, at the same time, there has been a push towards more frequent dialysis, though no conclusive studies have demonstrated a mortality benefit in patients on nocturnal hemodialysis (HD) or daily home HD. Unfortunately, it is unlikely that we will see any more guidance in this area in the coming year, as prospective randomized, clinical trials are very expensive and difficult to do.
For all of us, each New Year gives us the opportunity to renew our commitment to improve the health and well-being of each of our patients with kidney disease.
Anthony J. Bleyer, MD
Professor of Internal Medicine/Nephrology
Wake Forest University School of Medicine Winston-Salem, N.C.
- Wei C, El HS, Li J, et al. Circulating urokinase receptor as a cause of focal segmental glomerulosclerosis. Nat Med 2011;17:952-960.
- Mele C, Iatropoulos P, Donadelli R, et al. MYO1E mutations and childhood familial focal segmental glomerulosclerosis. N Engl J Med 2011;365:295-306.
- Genovese G, Friedman DJ, Ross MD, et al. Association of trypanolytic ApoL1 variants with kidney disease in African Americans. Science 2010;329:841-845.