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The Global Kidney Academy (GKA) has launched a new educational website aimed at providing Nephrologists in emerging countries with an interactive and up-to-date range of learning and advisory resources. Registration on OLA (OnLine Academy) gives you full access to the website.
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I strongly encourage the readers of Nephron Digest to engage in a dialogue by emailing me to discuss issues of global nephrological interest. These would be addressed by expert members of the editorial board of Nephron. Also readers are encouraged to request topics that they would like to be updated upon through the Mini Review series of Nephron Clinical Practice.
Professor Meguid El Nahas, PhD, FRCP
Editor, Nephron Clinical Practice
m.el-nahas@sheffield.ac.uk
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Digest of issue 119/1/2011
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IgA-Dominant Postinfectious Glomerulonephritis: A New Twist on an Old Disease (Samih H. Nasr, Rochester, Minn. and Vivette D. D’Agati, New York, N.Y.; Nephron Clin Pract 2011;119:c18-c26). The review by Nasr and D’Agati draws the reader’s attention to the changing nature of postinfectious glomerulonephritis. IgA-dominant postinfectious glomerulonephritis is increasingly being recognized. The article highlights the fact that this form of acute glomerulonephritis is more likely to occur in the elderly, the immunocompromised and those with diabetes. It also stresses the association with staphylococcal infections and the range of histological changes including the mesangioproliferative form associated with IgA deposits. In developing countries, including the Far East, where IgA nephropathy is quite common, it is important to distinguish between postinfectious IgA nephropathy and an acceleration of idiopathic IgA nephropathy or a superimposed infection. In addition to hypocomplementemia and subepithelial immune deposits characteristic of postinfectious glomerulonephritis, patients with postinfectious IgA-dominant glomerulonephritis tend to present frequently with AKI when compared to those with idiopathic IgA nephropathy. The poor prognosis and lower recovery rate associated with IgA-dominant postinfectious glomerulonephritis is attributed to the associated comorbidities. Nephrologists should be aware of this entity and include it in the differential diagnosis of elderly patients presenting with AKI.
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The ‘Centre Effect’ in Nephrology: What Do Differences between Nephrology Centres Tell Us about Clinical Performance in Patient Management? (Hodsman and colleagues, (Bristol and Southampton; Nephron Clin Pract 2011;119:c10-c17). This review by Hodsman and her colleagues from the UKRR Centre in Bristol examines an important and timely issue, that of the 'centre effect' in healthcare delivery. Increasingly, commissioners of healthcare assess the quality of care delivery by drawing comparisons to national and international 'standards' and link the care delivered to the resources allocated. National/international comparisons are not always applicable in view of a number of variables that impact on a given healthcare centre. The review discusses the different factors affecting healthcare delivery including the patients' case mix and organisational characteristics ('compositional effect'). Moreover, geographical and sociodemographic factors may affect a centre performance, including poverty with associated poor compliance and difficulties in accessing available services. The authors discuss how the gap and linkage between centre provisions and patients' outcome can be studied and closed. Focusing on a multi-variable quality performance, rather than on individual parameters/processes, may ultimately provide a more holistic and successful approach to quality and outcomes.
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Parallel Deterioration of Albuminuria, Arterial Stiffness and Left Ventricular Mass in Essential Hypertension: Integrating Target Organ Damage (E. Andrikou and colleagues, (Athens; Nephron Clin Pract 2011;119:c27-c34). Andrikou and colleagues report on 428 non-diabetic untreated hypertensives' ACR (urine albumin:creatinine ratio) and c-f PWV (pulse wave velocity, a measure of arterial stiffness). Age, male sex, 24-hour systolic BP, ACR and c-f PWV were independent predictors of left ventricular hypertrophy (LVMI). Increased ACR in conjunction with pronounced arterial stiffness is accompanied by augmented LV mass and higher LVH rates. The close interrelationships between albuminuria, c-f PWV and LVMI suggest parallel target organ damage progression. This is not surprising since untreated
hypertension is likely to have a detrimental effect on a number of end-organs including arteries, heart and kidneys. I have put forward the Cardio-Kidney-damage (C-K-D) concept a few years ago to highlight such a close link between hypertension, systemic vascular damage and albuminuria in the community. It is often said that patients with CKD have higher CVD risk, but this may simply reflect that patients with CKD in the community already suffer from underlying CVD and therefore would naturally have higher CVD mortality. Of interest, the prognosis of these patients has recently been shown to be predictable by conventional CVD risk scores (like the Framingham Risk Score), with little added value of adding albuminuria or GFR to the scoring system!
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Prevalence of Chronic Kidney Disease and Associated Risk Factors, and Risk of End-Stage Renal Disease: Data from the PREVADIAB Study (J. Vinhas and colleagues, Coimbra; Nephron Clin Pract 2011;119:c35-c40). The authors analyzed data from a nationally representative sample of 5,167 subjects, and estimated the prevalence of CKD stages 3 to 5 to be around 6.1. The prevalence of risk factors such as diabetes (11.7%), obesity (33.7%), and metabolic syndrome (41.5%) was similar to that in the US, but greater than in most European countries. The risk of ESRD was greater than in other European countries, but lower than in the US. The authors conclude that the high incidence of ESRD among the Portuguese population is not due to a greater prevalence of CKD but may be associated with a higher rate of CKD
progression. Caution in the interpretation of CKD prevalence in populations should be exerted when evaluating such reports as cross-sectional, single test analyses have been associated with over-reporting of CKD. Also, a high ESRD/CKD ratio may be due to faster progression but also to lower mortality as the majority of CKD patients do not reach ESRD, but instead die from CVD. It would be interesting to know if Portugal has a lower CKD3-4 mortality and also if current global efforts to reduce CVD mortality will lead to an increased burden of ESRD worldwide..?!.
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