KDIGO Glomerular Disease Guidelines: ANCA vasculitis

Pauci immune focal and segmental necrotizing GN guidelines by KDIGO

1. Initial treatment( cyclophosphamide and steroids) ( Grade 1A)
2. Rituximab and steroisd be used as alternative when above is contraindicated ( Grade 1B)
3. Plasmapheresis be added if there is rapid rise in crt or on dialysis (Grade 1C)
4. Plasmapheresis be added for pulmonary hemorrhage( Grade 2C)
5. Overlap diseases of ANCA and anti GBM - use plasmapheresis (Grade 2D).
6. If dialysis dependent for 3 months, stop cyclophosphamide if no extra renal manifestations( Grade 2C).
7. Maintenance therapy should be used if achieved remission ( Grade 1B)
8. Continue maintenance therapy for 18 months who achieved remission ( Grade 2D).
9. No maintenance in dialysis dependence and no extra renal manifestations ( Grade 1C)
10. Azathioprine is first choice at 1-2mg/kg/day orally as maintenance therapy ( Grade 1B)
11. MMF up to 1mg BID if above not possible( Grade 2C)
12. Bactrim use as adjunct( Grade 2B)
13. Methotrexate for maintenance  if intolerant to azathioprine and MMF if GFR >60 ( Grade 1C)
14. Etanercept should not be used as adjunct therapy ( Grade 1A).
15. Severe Relapse should be treated just like initial disease ( Grade 1C)
16. Other relapses should mean to re starting maintenance therapy ( Grade 2C)
17. Resistant disease:- Rituximab should be used ( 1C), IVIG( 2C) and plasmapheresis (2D)
18. ANCA titer alone should not change therapy ( Grade 2D)
19. Delaying transplantation till complete extrarenal manifestations have been in remission for 12 months( Grade 1C)
20. Not delaying transplantation for those in complete remission but still ANCA positive( Grade 1C).

For full details: http://www.nature.com/kisup/journal/v2/n2/pdf/kisup201226a.pdf
Image source: UNC kidney center website

KDIGO Guidelines for Glomerular Diseases: LUPUS NEPHRITIS

KDIGO is publishing guidelines in Glomerular Diseases in Kidney International

Topic: Lupus Nephritis


1. Class I LN be treated by extra renal manifestations rather than renal ( 2D)
2. Class II LN - No specific renal treatment if <1gm of proteinuria( 2D)
3. Class II LN- Proteinuria >3gm be treated with steroids or CNI like a minimal change disease (2D)
4. Class III LN- Steroids (1A) + either cyclophosphamide or MMF (1B)
5. Class III LN- if first option is not working to change to the alternative option above in 3 months (2D)
6. Class III Maintenance - Imuran or MMF ( 1B) and low dose steroids for one year (2D)
7. Class IV - same as Class III as above
8. Class V- If normal kidney function, and non nephrotic range proteinuria, conservative management and treatment dictated by extra renal manifestations( 2D)
9. Class V- persistent proteinuria:- steroids + cyclophosphamide and or CNI or MMF or Imuran ( 2D)
10. All patients should be on hydroxycholoroquine (2C)

For other detailed recommendations look at http://www.nature.com/kisup/journal/v2/n2/pdf/kisup201225a.pdf

KDIGO Guidelines for Glomerular Diseases: HSP

KDIGO released guidelines for glomerular diseases in Kidney International this year.

Topic: Henoch Schonlein Purpura Nephritis


1. HSP nephritis and persistant proteinuria of 0.5-1g/d be treated with ACEI or ARB( Grade 2D)
2. If proteinuria is >1gm, to be treated just like IgA nephropathy with steroids for 6 months
3. Steroids should not be used to prevent HSP Nephritis ( Grade 1B)
4. Crescentic HSP Nephritis should be treated with Steroids and alkylatic agents( Grade 2D)

For full article , look at
http://www.nature.com/kisup/journal/v2/n2/pdf/kisup201224a.pdf

Healthcare in India exposed!

Aamir Khan( a well known Bollywood star) exposes indian societal issues nicely in this TV show.
His latest episode was on health care and he addresses multiple issues that Indian Healthcare is behind.
1. Corruption
2. Medical Mistakes
3. No punishment for corrupt and mal practice doctors
4. Rise of private medical colleagues and their costs.

Interestingly one of the topics in the discussion was on kidney and pancreas transplantation.
Have a look

KDIGO Glomerular Diseases Guidelines: IgA Nephropathy

KDIGO just released guidelines for GN in a supplement in KI

Topic: IgA Nephropathy


1. Long term ACEI or ARB for proteinuria >1gm( Grade 1B)
2. ACEI or ARB treatment if proteinuria between 0.5gm to 1gm ( Grade 2D)
3. Patients with persistent proteinuria >1g/d despite 3-6 months of conservative management, and GFR >50ml/min get 6 month course of steroids (Grade 2C)
4. Not use cyclophosphamide or aza in IgA unless there is RPGN with crescents ( Grade 2D)
5. Not use cytotoxic agents for GFR< 30ml/min unless there is RPGN ( Grade 2C)
6. Fish oil is recommended if proteinuria is >1gm/d ( Grade 2D).
7. Not using antiplatelet agents in IgA( Grade 2C).
8. Minimal change with IgA:- treat like minimal change ( Grade 2B)
9. AKI associated with MCD:- perform a kidney biopsy in AKI with macroscopic hematuria if no change in renal function for 5 days
10. General supportive care for AKI in IgA for biopsy showing ATN( Grade 2C)
11. Steroids and cyclophosphamide in crescentic IgA( Grade 2D).
12. Tonsillectomy is not recommended ( Grade 2C)

For full recs see http://www.nature.com/kisup/journal/v2/n2/pdf/kisup201223a.pdf

KDIGO Guidelines for Glomerular diseases: Infection related GN

KDIGO guidelines published this year in KI supplement.
TOPIC: Infection related GN

1. Treat the underlying infectious disease for the following: Post streptococal GN, infective endocarditis related GN and shunt nephritis.
2. For Hep C related GN, and CKD stage 1 and 2, combined treatment with anti virals ( Grade 2C).
3. For Hep C related GN, CKD stage 3,4,5- suggest monotherapy with pegylated interferon with dose adjustment ( Grade 2D).
4. For Hep C with mixed cryo with nephrotic proteinuria or progressive renal disease: plasmapheresis, rituximab or cyclophosphamide  in conjunction with IV steroids and antiviral therapy( Grade 2D).
5. For Hep B related GN, treatment of Hep B with interferon alpha ( Grade 1C).
6. For HIV associated GN, anti retro virals are the most important regardless of CD4 count ( Grade 1B).

http://www.nature.com/kisup/journal/v2/n2/pdf/kisup201222a.pdf

KDIGO Guidelines for Glomerular Diseases: MPGN

  KDIGO guidelines are proposed this year in recent Kidney International on glomerular disease.

Topic: MPGN

1. It is very important to evaluate for secondary causes

2. Conditions to consider are: Infections like Hepatitis C,  autoimmune diseases, MGUS, complement dysregulation and chronic thrombotic microangiopathy and to treat those underlying conditions.

3. Adults and children with idiopathic MPGN with nephrotic syndrome and progressive decline in renal function receive oral cyclophosphamide or MMF with low dose alternating steroid for 6 months( Grade 2D).

Take a look at the full article at: http://www.nature.com/kisup/journal/v2/n2/pdf/kisup201221a.pdf