MGRS: We need to think a new way!

Many times we have come across monoclonal deposition in the kidney of Ig and there is no bone marrow or blood findings to suggest malignancy.  Lately, there has been findings of association of many such instances with glomerular diseases:

1. MGUS with MPGN
2. New findings of proliferative GN with monoclonal deposits( but no real bone marrow findings)
3. Immunotactoid GN and its's perhaps relationship with CLL and monoclonality
4. Fibrillary GN and similar findings ( less often than immunotactoid GN)
5. LCDD but no BM findings fully suggestive of >10% plasma cells to make a Myeloma diagnosis.

Clearly, there is monoclonal gammopathy of RENAL significance(MGRS) in all above states and perhaps we need to re look at a group of these disease states more carefully. Unfortunately, no studies exist to tell us how to treat them. Do we treat them as denovo renal diseases or treat the underlying plasma cell or B cell clone?

Some recent articles are worth a read to perhaps start some thought provoking discussions re these associations.

Glucoretics have arrived: A new class of anti diabetic drugs

The U.S. Food and Drug Administration approved the drug, Invokana, after data showed it was effective in lowering blood sugar in patients with Type 2 diabetes.
Known chemically as canagliflozin, Invokana is a member of a new class of diabetes treatments called sodium-glucose co-transporter-2 (SGLT2) inhibitors that lower blood sugar by blocking reabsorbtion of glucose and increasing its excretion in urine.
To me this sounds like a glucoretic. 

Some of the animal data had shown promise and then these class of drugs came into trials. Preclinical and clinical research has demonstrated that inhibition of SGLT2, the major pathway of renal glucose reabsorption, leads to increased urinary glucose excretion with concomitant reductions in fasting and postprandial plasma glucose levels, HbA1c levels and body mass. In animal studies, the drugs have been correlated with an increase in urinary volume and a reduction in body fat but not water content.They do mention that it is contra indicated in CKD and ESRD patients( well if you don't make urine, this will not be working for sure).

Why is this drug important for nephrologists? Well increased osmotic diuresis can perhaps lead to a pre renal insults, more urinary tract infections( due to the glucorectic effect), perhaps proximal tubular dysfunction or better yet- maybe it gives additional benefit of water loss leading to good blood pressure control. A recent study already looked at the drug's effect on CKD stage 3 patients. It was deemed safe in CKD Stage 3 based on that one study. 

Novel mechanism, lets wait and watch.

Clinical Case 71: Answers and Summary

WHAT IS THE HIGHEST SERUM CREATININE THAT YOU HAVE ENCOUNTERED?

15-20mg/dl	11 (18%)
21-30mg/dl	16 (27%)
31-40mg/dl	12 (20%)
41-50mg/dl	8 (13%)
>50mg/dl	12 (20%)

Only two references I could find reporting high creatinine levels. 

One is Dr Topf's blog PB fluids reference of crt level in 34-37 range. But the highest reported in the literature is 61mg/dl. The poll above shows that 20% of you have seen such high creatinine levels. Disease states that cause such high creatinine likely are to be Rhabdomyolysis and obstruction. But the case reported above was hypertension. Cast nephropathy might be another form of obstructive disease where such high creatinines might be noted. 

Tele-Nephrology? Pros and Cons

Telenephrology may contribute to an effective use of health facilities by allowing patients to be treated in primary care with remote support by a nephrologist. A recent study done in Netherlands showed that telenephrology consultations( done via phone remotely or video conferencing) looked at reduction of in person referrals and response time. Time investment per consultation amounted to less than 10 minutes. Consultations were mainly performed during office hours. Response time was 1.6 days.  Most questions concerned estimated glomerular filtration rate, proteinuria, and blood pressure. The authors concluded that a web-based consultation system might reduce the number of referrals and is usable. Another study done in Russia also shows some promise.  A nice study from Canada showed that a positive response. The analysis of staff hours worked showed almost no increase following the introduction of telemedicine. Telemedicine is therefore feasible for follow-up care of remote chronic kidney disease patients.

Peritoneal dialysis seems to be a place where this might be very useful or home dialysis. Few papers have looked into positive aspects of this form of medicine. Remote monitoring of the patient on peritoneal dialysis offers the benefits of real-time monitoring and recording of the therapy and interactive interface with the nephrology team can allow both acute 'trouble shooting' for problems as well as a means to interact with the patient for their monthly evaluation. This remote monitoring may increase compliance. Recent advances in telemonitoring, remote network access and sensor technologies have made such remote monitoring of peritoneal dialysis therapy a potentially user friendly option. A recent review summarizes the pros and cons of using such techniques.

Other studies have shown otherwise. In France, the experience seemed unfruitful and had to be shut down.

Border Crosser's Nephropathy

A recent article in Renal Failure discusses this novel entity called Border Crosser's nephropathy. Immigrants who were attempting to cross borders in Arizona were wandering for days without food and water and developed AKI secondary to heat exhaustion leading to rhabdomyolysis. The authors term this AKI as Border Crosser's nephropathy. They studied a case series of patients and found that mean days on desert was 4 days and few patients required dialysis. Most CPK were range of 1101 to 447,966IU/L.
Largest CPKs are reported in such patients. This appears to be a risk that we have to keep in mind. Unclear to me if this truly deserves a separate name or can we just call it volume depletion and heat exhaustion leading to rhabdomyolysis leading to ATN.

Nephrology: Name origin

Jean Hamburger from France had named the term " Nephrology" for study of kidney diseases. A pioneer in the field of kidney diseases, Dr Hamburger was a pioneer in the early times of dialysis and transplantation.
A recent memoir regarding his work is published in PEHM

He was a pioneer in nephrology, coined the term intensive care medicine and was a pinnacle for humanism in medicine.  He is considered the father of French Nephrology. If he coined the term- he is the father of nephrology for all of us.

Interesting quote from the paper " Nephrology would have probably been named kidney medicine, under the strong influence of  the American medicine, while the Greek etymology may be seen as a further witness of the strong link between humanities and medicine, of which the whole life of Jean Hamburger is
an interesting example."

Lets celebrate the history of nephrology this month - the National Kidney Month-- or rather World Kidney month with respect to him.

Check out other historical interest blogs.

NephMadness Brackets

Here are my selections for the eAJKD's mega nephrology competition. 

I think PD is an important form of dialysis that is home based and deserves to be offered first and hence PD first. APOL1 is one the most important genetic discoveries of all times. ASN is the most important organization to help with research and progress in Nephrology. A tough battle for most players but I feel that Kidney Transplantation is the winner!  This surgical procedure has been the best thing we can offer our patients!