Lee Gs

Global evolutionary trend of the prevalence of primary glomerulonephritis over the past three decades.

Objective: The prevalence of primary glomerulonephritis in Singapore is compared with that of 28 other countries to review changing trends in the evolution of primary glomerulonephritis in Asia and other countries. Method: 2,586 renal biopsies in Singapore over the past 3 decades were reviewed and compared with data from 28 other countries. Results: In the 1st decade most Asian countries have mesangial proliferative glomerulonephritis as the most common form of primary glomerulonephritis, and in the 3rd decade there has been a dramatic increase in focal and segmental glomerulosclerosis reflecting aging and obesity in keeping with more developed countries. IgA nephritis remains the commonest glomerulonephritis in many countries. Membranous glomerulonephritis continues to be more prevalent in Western countries while mesangial proliferative glomerulonephritis remains prevalent in many Asian countries. Conclusion: Apart from geographical and genetic influences, socioeconomic factors may play a role in the evolution of the biopsy pattern in some countries. Worldwide, the prevalence of focal segmental glomerulosclerosis continues to increase. In third world countries some of the commoner forms of glomerulonephritis are related to infections, in contrast to developed countries where the antigenic exposure may be related to diet, allergens and other industrial agents.

Protein Selectivity: A Prognostic Index in IgA Nephritis

Among 98 patients with IgA nephritis who had protein selectivity studies performed, 54% had nonselective proteinuria and the remaining 46% had selective proteinuria. Patients with nonselective proteinuria had a higher incidence of glomerulosclerosis. At the end of a 4-year follow-up period, patients with nonselective proteinuria had lower creatinine clearance, higher incidence of hypertension and chronic renal failure when compared to patients with selective proteinuria. Six out of eleven patients (55%) in the study who had the nephrotic syndrome had selective proteinuria. Among these 6 patients, 1 had spontaneous remission and 5 responded to steroid or cyclophosphamide therapy. The remaining 5 patients with nonselective proteinuria did not respond to therapy. In the patients who had selectivity studies repeated, the data showed that the selectivity index (SI) can fluctuate depending on the clinical course of the patients. SI can therefore be used to monitor the progress of patients on long-term follow-up. Protein selectivity appears to be a useful prognostic index in IgA nephritis. For patients with the nephrotic syndrome it may serve as a guide to therapy.

What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?

Aim:  Previous studies have focused either on advance medical directives rather than advance care planning (ACP), or on patients perspectives on ACP rather than those of the health‐care providers. This study aimed to explore the knowledge, attitudes and experience of renal health‐care professionals in Singapore on ACP for patients with end‐stage renal failure.

Isoelectric focusing and selectivity index in IgA nephrotic syndrome.

Proteinuria in 13 patients with IgA nephritis with nephrotic syndrome (IgANS) was analysed by isoelectric focusing (IEF) and compared with 12 patients with minimal change nephrotic syndrome (MCNS) (n = 8) or focal global sclerosis nephrotic syndrome (FGS) (n = 4) to determine the pattern of proteinuria on IEF and to assess the value of IEF and protein selectivity index (SI) as predictors of response to therapy with predisolone or cyclophosphamide. Steroid/cyclophosphamide responsive patients with IgANS had SC:UA (cationic serum albumin with anionic urine albumin) or SA:UC (anionic serum albumin with cationic urine albumin) IEF patterns and steroid/cyclophosphamide unresponsive patients with IgANS had an SC:UC (cationic serum albumin with cationic urine albumin) IEF pattern. The majority of patients with MCNS or FGS who had an SA:UC IEF pattern were steroid responsive. SI was a better predictor of steroid/cyclophosphamide responsiveness in patients with IgANS (r = 0.78, p < 0.002 compared to IEF, r = 0.64, p < 0.02).

Pattern of proteinuria in IgA nephropathy

Summary: Proteinuria is one of the bad prognostic indices in IgA nephritis (IgAN). This study compares the pattern of protein excretion in 10 patients with IgAN (IA) with that 5 years later (IB), when they developed renal impairment or hypertension. The pattern of proteinuria was analysed by SDS‐PAGE and isoelectric focusing (IEF) and assayed for orosomucoid, α‐1‐microglobulin, retinol‐binding protein, lysozyme, beta‐2‐microglobulin and N‐acetyl‐β‐D‐glucosaminidase activity. The data suggest that the changing pattern of proteinuria from IgA1 to IgA2 may reflect hyperfiltration as well as tubular injury.

Warfarin-related nephropathy in patients with chronic kidney disease

To the Editor: We read with great interest the entity described by Brodsky et al.1 as warfarin-related nephropathy, which occurs in patients with chronic kidney diseases treated with anticoagulant doses of warfarin. In the 1970s and early eighties, the combination therapy of cyclophosphamide, dipyridamole, and warfarin, known as the Melbourne Cocktail, was introduced and popularized by Professor Priscilla Kincaid-Smith. KT Woo, on one of his sabbaticals at the Royal Melbourne Hospital, was tasked by Kincaid-Smith to analyze the results of patients with immunoglobulin A nephritis treated with the above triple therapy in which warfarin was given in anticoagulant doses to reduce thrombotest values to between 7 and 15%. His analysis had shown that patients on triple therapy had worsening of renal function compared to the control group, in whom renal function did not deteriorate as much. Also, in the treatment group, there was more glomerular bleeding as evidenced by urinary red blood cell counts compared with the control group. However, proteinuria improved in the treatment group though there was no improvement in renal function. The data were subsequently published by Walker et al.2

A retrospective Aliskiren and Losartan study in non-diabetic chronic kidney disease.

AIM To assess the efficacy of combined Aliskiren and Losartan vs high dose Losartan and Aliskiren alone in chronic kidney disease (CKD). METHODS This is a retrospective study of 143 patients with non-diabetic CKD comparing combined Aliskiren (150 mg/d) with Losartan (100 mg/d) therapy vs High dose Angiotensin receptor blockers (ARB) (Losartan 200 mg/d) and the third group Aliskiren (150 mg/d) alone. This study involved only patient medical records. Entry criteria included those patients who had been treated with the above drugs for at least 36 mo within the 5 years period; other criteria included proteinuria of 1 g or more and or CKD Stage 3 at the start of the 36 mo period. The study utilised primary renal end points of estimated Glomerular Filtration Rate (eGFR) < 15 mL/min or end stage renal failure. RESULTS Patients treated with high dose ARB compared to the other two treatment groups had significantly less proteinuria at the end of 36 mo (P < 0.007). All 3 groups had significant reduction of proteinuria (P < 0.043, P < 0.001). Total urinary protein was significantly different between the 3 groups over the 3-year study period (P = 0.008), but not eGFR. The changes in eGFR from baseline to each year were not significantly different between the 3 therapeutic groups (P < 0.119). There were no significant differences in the systolic and diastolic blood pressure between the 3 drug groups throughout the 3 years. The incidence of hyperkalemia (> 5.5 mmol/L) was 14.2% (7/49) in the Combined Aliskiren and ARB group, 8.7% (4/46) in the Aliskiren alone group and 6.3% (3/48) in the High dose ARB group (P < 0.001). CONCLUSION This study in non-diabetic CKD patients showed that Combination therapy with Aliskiren and ARB was effective but was not safe as it was associated with a high prevalence of hyperkalaemia.