Glomerulonephritis registry: Need of the hour.

Glomerulonephritis (GN) is one of the most common causes of end-stage renal disease (ESRD) globally, and arguably, may be the leading cause in some of the developing countries where diabetes is fast catching up.[12] With prompt diagnosis and appropriate management, progression to renal failure can be slowed down in most and completely avoided in some of these patients. Data from large, multicenter trials to guide management of GN is limited, although this picture may be changing fast.[3]

Longitudinal follow-up of these patients in dedicated GN clinics can potentially facilitate monitoring of disease trajectories, and thereby their management. In this issue of the journal, Atlani et al.[4] have reported their initial experience of setting up of a dedicated GN clinic. In a cohort of 78 patients, over about 20 months of follow-up, 10 patients suffered either significant decline in renal function or ESRD. About 30% of the patients were categorized as “therapy resistant,” while others achieved either complete or partial response. Focal segmental glomerulosclerosis (FSGS) and IgA nephropathy fared the worst. Results of this study are consistent with the observed presentation and course of these diseases in India. IgA nephropathy, which is the most common cause of GN worldwide, is classically thought to have a benign course. However, many reports have highlighted the “malignant course” of this disease in South East Asia.[5] This may have to do with the genetic differences, late presentation, association with severe hypertension, and lead time bias. FSGS is known to be resistant to the initial therapy in about one-third of the patients, which was also observed in the present study. FSGS is increasingly understood as a “pattern of glomerular injury” in response to various etiologies rather than a disease by itself. Clinical, imaging, electron microscopic, and genetic evaluation can help identify early those patients who would not be benefited by (and therefore spared from the harm of) immunosuppression.[6]

Irrespective of the etiology, aggressive nonimmunosuppressive measures to control proteinuria and hypertension are the cornerstone of management of these patients.[7] Dedicated remission clinics have previously reported excellent long-term outcomes with this approach. Ruggenenti et al.[8] have reported that during a median follow-up of 4 years, the monthly rate of glomerular filtration rate (GFR) decline was significantly lower in their remission clinic cohort (median − 0.17 versus − 0.56 mL/min per 1.73 m2; P < 0.0001) and ESRD events were significantly reduced (3.6% versus 30.4% reached ESRD). Similarly, Mani et al.[9] have reported use of high-dose dual renin angiotensin system (RAS) blockade in Indian population to prevent chronic kidney disease. These approaches also involved the use of “controversial” dual RAS blockade and demonstrated its safety and efficacy. As data on possible harm of dual blockade is mainly derived from diabetes trials, and given the initial encouraging results, large-scale evaluation of this strategy in GN is urgently needed.

Racial differences in the presentation, natural course, and response to the therapy of these diseases[1011] make strong case for country-specific multicenter collaboration to establish GN registries, which can immensely contribute to the understanding of the natural history, treatment strategies, and prognosis of GN.