Carmine Zoccali

Hans Joachim Anders (Munich, Germany) drives us in the fascinating story of innate immunity, toll like receptors (TLRs) and renal damage in experimental models. TLRs  and other receptors recognise pathogen-associated molecules which act as endogenous adjuvants and  trigger proinflammatory mediators that contribute to the immunity-mediated renal damage. This type of damage depends on the cell type-specific expression of these receptors. Thus bacterial DNA induces lupus nephritis in the predisposed mouse by activating  several  immune responses via TLR9 such as local activation of dendritic cells in the kidney and the same cells  in lymph nodes and in the spleen which enhances the autoimmune process. Activation of TLR3, a receptor for viral RNA, can induce mesangiolysis, if mesangial cells have been preactivated but, because TLR3 is absent in B cells,  viral RNA cannot induce antibodies or autoantibodies in this model.
Dr. Matthias Kretzler  (Ann Arbor, USA) nicely illustrates the intricacies of the trascriptional control mechanism in glomerular diseases. He envisions a personalized molecular nephrology approach but ends with a cautionary note stating that specific studies are required to evaluate the diagnostic power of the new techniques and to modulate biologically or pharmacologically identified pathways.
Dr. Pierre Ronco (Paris, France) focuses on the importance of alloimmunization in glomerular diseases, an area  where he has given outstanding contributions by identifying  a new disease entity, FMAIG (Feto Maternal AlloImmune Glomerulopathy.
Finally, Dr. Seiji Ueda (Karume, Japan) produces very stimulating data showing that ADMA-induced endothelial dysfunction  plays an important role  in renal damage by way of peritubular capillary loss.
He demonstrates that in experimental models countering ADMA prevents renal function loss. Enhancement of the activity of the enzyme that degrades ADMA (DDAH)  may in the future become a novel therapeutic strategy for treatment of patients with CKD.

We have now completed the “Cardiovascular Risk assessment and monitoring in ESRD” survey. Over 800 nephrologists participated in this survey. About 84% of respondents rarely or never use 24ABPM for defining the BP status of dialysis patients. Yet an unexpectedly high minority (7%) regularly uses this technique. In contrast it was  not surprising  that those who use 24ABPM employ it independently of the presence of office hypertension. Likely, these respondents apply 24ABPM to look at the circadian profile (the BP component, more predictive of adverse cardiovascular events in this population, is a nocturnal BP rise). In line  with guidelines recommendations, 91% and 71% of participants systematically perform ECG and echocardiographic studies in patients starting RDT. Furthermore the application of echocardiography for risk monitoring is more frequent (13 months vs 36 months) than indicated in guidelines recommendations. Remarkably, 7% of participants also measure Pulse Wave Velocity, i.e. a much intriguing technique which is not recommended in current guidelines. Among biomarkers, C Reactive Protein (CRP) wins hands down. CRP is indeed almost universally applied (95%) and the measurement is repeated  on average every 4 months. Troponin T and BNP are rarely used (15% and 7%) even though those who use these biomarkers repeat the measurement with the same frequency of CRP. Overall,  European nephrologists are much alerted on countering the high cardiovascular risk of ESRD patients. Although the use of imaging studies and biomarkers does not coincide with that given in current guidelines,  the general attitude is to apply  more intensive risk assessment and risk monitoring  protocols. Melius abundare  quam deficere…..

Enjoy your NDTe!

Carmine Zoccali – Editor in Chief NDT-Educational