The edition · Nephrology
Complement inhibitors arrive without the rules for using them
An International Society of Nephrology forum sets out what is and is not known about placing alternative-pathway inhibitors in C3 glomerulopathy and IgA nephropathy; and a KDIGO implementation summit names the barriers that keep guideline therapy out of Asia-Pacific practice.
The edition in brief
The 2025 International Society of Nephrology Forum on Complement Therapeutics reviewed how alternative-pathway complement inhibitors should be used in C3 glomerulopathy, immune-complex membranoproliferative glomerulonephritis and IgA nephropathy, now that trials in all three have succeeded. Complement overactivation is the primary driver in C3 glomerulopathy and immune-complex disease; in IgA nephropathy it is increasingly implicated as a secondary contributor to kidney damage rather than the cause. The panel identified the unresolved questions as how complement biomarkers, complement autoantibodies, genetics and the kidney biopsy should guide who is treated. The SEISMIC summit addressed the practical side of the same problem for C3 glomerulopathy and immune-complex membranoproliferative glomerulonephritis: timely diagnosis of an ultrarare disease spectrum, how management changes now that iptacopan and pegcetacoplan are approved, and the barriers to equitable access. A Cochrane review of lower-limb neuromuscular electrical stimulation in dialysis found twelve randomised trials with 439 participants randomised and 299 contributing data. Certainty was low to very low throughout. The intervention made little or no difference to systolic blood pressure (mean difference 5.54 mmHg, 95% CI −4.02 to 15.09), diastolic pressure or resting heart rate, and no study reported fatigue, pain, infection or vascular access problems. A KDIGO implementation summit in Kuala Lumpur, with participants from 13 Asia-Pacific countries, set out barriers to delivering the 2020 blood pressure and 2022 diabetes guidelines in chronic kidney disease, across lifestyle intervention, team-based care, albuminuria screening and guideline-directed medical therapy.
Complement inhibitors work; who should get them is unsettled
Obtain biopsy and complement studies before starting a complement inhibitor, because the criteria for selecting patients are still being worked out.
Access, not evidence, is the barrier in C3 glomerulopathy
Make sure a membranoproliferative biopsy is fully characterised and the patient is linked to a centre, because classification now determines access to treatment.
Electrical stimulation in dialysis is still an open question
Neuromuscular electrical stimulation has no evidence base for routine use in dialysis — if your unit uses it, measure fatigue and function.
Check the potassium result against the sample, not the patient
Repeat an isolated raised potassium with attention to sampling before stopping a renin-angiotensin blocker.
KDIGO names what stops its guidelines reaching Asian patients
Start by measuring albuminuria reliably — it is the step the guidelines assume and the one most often missing.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for nephrology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free