Opinion: Should we focus on targeted therapy and use less of ACEi/ARB, SGLT2i?

In nephrology, we have traditionally focused on treating CKD and fibrosis, often resorting to "band-aid" therapies for many diseases. Most guidelines suggest starting with ACE inhibitors (ACEi) or angiotensin receptor blockers (ARBs), and more recently, adding SGLT2 inhibitors (SGLT2i). This approach has proven effective for diabetic nephropathy, advanced CKD, and perhaps secondary focal segmental glomerulosclerosis (FSGS). However, is this strategy appropriate for other glomerulonephritides (GNs) and disease states?

For instance, if proteinuria is high, KDIGO recommends ACEi/ARB and conservative management as the first-line treatment for IgA nephropathy (IgAN). Should we not reconsider this approach? Why not prioritize treating the underlying disease with targeted therapies first? If these fail or CKD progression continues, we could then add ACEi/ARB, SGLT2i, and other CKD medications. For example, in lupus nephritis (LN), we initially treat the disease itself. Yet, in many GNs, we start with "band-aid" medications, which often leads to the primary disease treatment being sidelined or neglected.

A paradigm shift is needed in renal medicine, especially as new targeted therapies for conditions like IgAN, C3 glomerulopathy (C3GN), membranous nephropathy, and APOL1-mediated FSGS emerge. We should consider starting with these targeted therapies, and following up with ACEi/ARB and SGLT2i as supportive measures.

I propose adopting a methodology similar to rheumatology and oncology, where disease-modifying agents are used as first-line treatments (supported by RCT data), followed by CKD agents. While there is currently no data to support this approach, a shift in mindset is necessary to design and conduct trials based on this concept. This is a lingering thought from a nephrologist who sees other fields advancing faster than ours.

In the News: Performance trends of Nephrology fellows in certification exams

 A news flash paper published recently in JASN showcased the down trending test scores of nephrology fellows in certification exams. The authors analyzed the data from 2010-2019 and found that the pass rate has been falling below the bench marks. Interestingly, they found that the factors associated with this decline were lower internal medicine exam scores, older age and training in a smaller program. In addition, female sex and being IMG were also associated with a lower board score. 

The IM board score as a predictor can make sense as both exams evaluate knowledge and skills of reasoning. Age over 33 performed less well than younger candidates is interesting. This could be because of non medical factors. Even since 2009 when I took my boards, the knowledge level has changed. There is more and more to read and more diseases to understand in medicine. Residency has not changed, Fellowship years have not changed. While knowledge and science has advanced, we have not changed our ways to teach and perhaps even consider changing the timeline of residency and fellowship. Fellows have family and other commitments as well and a well balanced life-work-training is critical for our trainees. 

The fact that graduates of the least competitive nephrology fellowship programs(smaller programs) performed worse after regression adjustment indicates there might be a peer effect, or advantages of a structured program at a larger academic center. 

IMGs were less likely to score high.  The field of Nephrology has seen an increase in IMG applicants.  In 2019, IMGs comprised nearly 70% of those taking the nephrology exam for the first time, an increase of more than eight percentage points from 2010. We keep forgetting that everyone learns differently- not everyone has a structure of learning in multiple choice questions in rest of the world; there are language barriers and other factors that play a role as well. Fellowship programs need to explore non ppt format of teaching and novel ways to teach the same material for varied type of learners. 

Finally, women were found to have lesser scores. To my knowledge, not sure of any published papers showing this difference in test taking strategies. I don't think we need to take any stake in these findings as these might be not of any significance. The editorial nicely reminds us to not take this finding seriously. 

What should be done?
Why can't we test the fellows on what we really encounter rather than esoteric rare and confusing diseases. Why can't the tests really mirror the life of a renal fellow and attending?
Institutions need to take ownership on better techniques and strategies to help their fellows. Many residencies may not be training them in proper test taking techniques. Institutional and program resources must support trainees’ needs, protect their time, and ensure education is prioritized.  

I can say from my personal example of few fellow I trained- had trouble passing the boards due to their test taking abilities. Their patient satisfaction scores as attendings are off the roof and their overall understanding of both patient care and medicine is excellent. They may not be a good test taker, but they can manage a good census, take care of patients and call for help when needed and effectively communicate with other doctors. They win patient trusts, they do well with following up and most important of all- they care! and want to be Nephrologists that matter. 

While test scores are important, failures sometimes teach us to be better and improve our abilities to be the best at what we do. But regardless, this is a wake up call for our field to improve as instructors and teachers and not disappoint our students. 

eAJKD: Interest in Nephrology declining

Interest in Nephrology is declining. Many of us are using new interventions to increase that interest. How do you measure that? Take a look at Tejas Desai et al in eAJKD blog.

eAJKD: Home Hemodialysis

Is there any future for Home Hemodialysis in the US? Check out the commentary from Dr. Mailloux on two recent articles in AJKD Dec 2011 issue on eAJKD

In The News-Final Blow on anemia agents

Check out the latest nytimes 2011 article on anemia:

http://www.nytimes.com/2011/06/25/health/policy/25drug.html?ref=gardinerharris