The edition · Nephrology
An early eGFR or albuminuria change may not mean the drug worked
Individual data from 49 trials and 66,449 participants found early shifts in GFR and albuminuria moved together almost as much on placebo as on treatment. Plus rituximab for refractory lupus nephritis, urine osmolality as a tolvaptan signal, and KDIGO's agenda for kidney care technology.
The edition in brief
Early markers: an individual-patient meta-analysis of 49 CKD progression trials with 66,449 participants found no trial-level relationship between treatment effects on early GFR change and on albuminuria (slope 0.00). Within individuals, a greater early GFR decline was linked to a fall in albuminuria of similar size in treatment (8.0% per SD) and control arms (6.6%), suggesting early changes largely reflect natural history rather than drug effect. Rituximab in lupus nephritis: 19 studies with 445 patients with relapsing or refractory disease found pooled complete renal response of 33% at 6 months and about 41–42% at 12–24 months, with overall response of about two-thirds and proteinuria down about 2.7 g/day, from mostly uncontrolled studies. Tolvaptan: a post hoc analysis of TEMPO 3:4 found the fall in urine osmolality at week 3 mediated part of tolvaptan's effect on eGFR at 3 years in 948 non-Japanese participants, but not in 138 Japanese participants, while the effect on kidney growth was direct in both. Technology: a KDIGO Controversies Conference set research priorities for digital tools to improve guideline-based kidney care, including living guidelines, integrated decision support, interoperability and evidence that tools reduce rather than widen disparities.
Rituximab rescue in refractory lupus nephritis: about two-thirds respond, mostly from uncontrolled data
Consider rituximab as rescue therapy for refractory lupus nephritis, with realistic expectations and after confirming true refractoriness.
Urine osmolality fall at three weeks partly explained tolvaptan's kidney benefit, in non-Japanese patients
An early fall in urine osmolality supports that tolvaptan is acting, but should not be used alone to decide whether to continue.
KDIGO sets an agenda for technology to close the gap in guideline-based kidney care
Use simple digital prompts to test and treat CKD in people with diabetes and hypertension; that is where technology helps most now.
Expect an eGFR dip after starting RAS blockade or an SGLT2 inhibitor
Do not stop RAS blockade or SGLT2 inhibitors for an expected early eGFR dip of up to about 30%.
Early GFR and albuminuria changes moved together on placebo too, so may not show drug response
Do not stop proven kidney-protective drugs because of early eGFR or albuminuria changes alone; they may reflect natural history.
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