NephSap: Onco-nephrology

This month, the ASN Nephsap is on my favorite topic of "onco-nephrology". Interestingly, its a nice case based approach with a lot of pictures. It highlights AKI in cancer patients, AKI with HSCT diseases and glomerular diseases with GVHD and HSCT, TMA and ends with chemotherapy in cancer patients and dosing in CKD and ESRD. Electrolyte disorders has been also discussed. Have a look at the entire nephsap, worth a complete read and much easier to read than other nephsaps. An editorial in JASN also summarizes this rising field in nephrology.

NEPHSAP review: Glomerular Disease: Hematuria Risk long term?

At Nephsap review, we discussed a question re asymptomatic isolated hematuria in an young adult and the discussion was regarding the long term risk to ESRD? Is it truly measurable risk?
Young adults often present with asymptomatic hematuria. This was elegantly studied by the researchers in Israel looking at close to a million sample size.  It was a retrospective cohort study using medical data from ages 16-25 (60% males and 40% females) who had been examined for fitness to the military.

Persistent asymptomatic isolated microscopic hematuria was diagnosed in 3690 of 1,203,626 eligible individuals (0.3%). After over 21 years, ESRD developed in 26( 0.7%) of the hematuria group and 529( 0.045%) without the hematuria group. This was a hazard ratio of 19.5.  A substantially increased risk for treated ESRD attributed to primary glomerular disease was found for individuals with persistent asymptomatic isolated microscopic hematuria compared with those without the condition. The authors concluded that the "presence of persistent asymptomatic isolated microscopic hematuria in persons aged 16 through 25 years was associated with significantly increased risk of treated ESRD for a period of 22 years, although the incidence and absolute risk remain quite low."

Nephsap review: Transplantation

A question encountered on our recent Nephsap review on transplantation:
What regimen would be the safest in pregnancy? If one had to choose between CNI + prednisone or CNI+ azathioprine. The groups were divided.
What is the data?
As you go down the list in immunosuppresive medications: most are C and below and no medication is a Risk category A or B.  Cyclosporine has the most data with tacrolimus with extrapolated data. Aza and MMF would be close to category D compared to CNIs which are more of a category C. Steroids would also fall in category C.  From a clinical prespective, the safest immunosuppression for a woman who wishes to get pregnant seems to be a combination of controlled CNI and prednisione. MMF should be discontinued.
What if you were on a steroid sparing protocol? Would you add steroids or AZA instead of MMF?
Azathioprine is teratogenic in animal studies.  It does cross the placenta/ and hematologic toxicities can happen to the fetus.  But a lot of pregnancies have been documented successfully at many transplant centers with AZA.  So some centers would choose to add AZA in this case but some might just do steroids and CNI. Due to lack of data, there is really no right answer. Risks and benefits of all agents have to be discussed and decisions made on an individual basis.

Ref:
http://www.ncbi.nlm.nih.gov/pubmed/21266268
http://www.ncbi.nlm.nih.gov/pubmed/20685549
http://www.ncbi.nlm.nih.gov/pubmed/18368705
http://www.ncbi.nlm.nih.gov/pubmed/16095516