The changing pattern of primary glomerulonephritis in Singapore and other countries over the past 3 decades.

This review of 2,586 renal biopsies over the past 3 decades in Singapore documents the changing pattern of glomerulonephritis (GN) from that of a third world country to that of a developed nation. In the 1st decade, mesangial proliferative glomerulonephritis was the most common form of primary GN, just as it was in the surrounding Asian countries. In the 2nd decade, the prevalence of mesangial proliferative GN decreased with a rise in membranous, GN which is also seen in China and Thailand. In the 3rd decade, there was a dramatic increase in focal sclerosing glomerulosclerosis. This increase reflects aging and obesity in keeping with more developed countries like Australia, India, Thailand and the United States of America. IgA nephritis remains the most common GN. Apart from the geographical influence, other socioeconomic factors play a significant role in the evolution of the renal biopsy pattern. Mesangial proliferative GN remains prevalent in many Asian countries, but in Singapore the prevalence is decreasing just as it is in Japan, Korea and Malaysia. Worldwide, the prevalence of focal sclerosing glomerulosclerosis continues to increase in many countries.

Beneficial effects of high-dose losartan in IgA nephritis.

AIM: Several short-term studies have reported the efficacy of high-dose ARB in reducing proteinuria in patients with diabetic nephropathy. The benefits of long-term high-dose ARB losartan in IgA nephritis have not been explored. METHOD: This was a 6-year randomized trial in 207 patients with IgA nephritis comparing high-dose ARB (losartan 200 mg/day) with normal dose ARB (losartan 100 mg/day), normal dose ACEI (20 mg/day) and low-dose ACEI (10 mg/day). Multivariate ANOVA was used to test the effect of drug treatment on both eGFR and total urinary protein (TUP). RESULTS: Comparing patients on high-dose ARB (n = 63) with those on normal dose ARB (n = 43), normal dose ACEI (n = 61) and low-dose ACEI (n = 40), patients on high Dose ARB had significantly higher eGFR (p < 0.0005) and lower proteinuria (p < 0.005) at the end of the study. The loss in eGFR was 0.7 ml/min/year for high-dose ARB compared to 3.2 - 3.5 ml/ min/year for the other 3 groups (p = 0.0005). There were more patients on high-dose ARB with improvement in eGFR compared to other 3 groups (p < 0.001). CONCLUSION: Data from this study suggest that high-dose ARB therapy is more efficacious in reducing proteinuria and preserving renal function when compared with normal dose ARB and ACEI. In Year 5, patients on high-dose ARB had a gain in eGFR suggesting that there is possibility of recovery of renal function in these patients on long-term high-dose therapy.

Retarding the progression of diabetic nephropathy in type 2 diabetes mellitus: focus on hypertension and proteinuria.

INTRODUCTION: There is a worldwide pandemic of type 2 diabetes mellitus and approximately one-third of these individuals will develop diabetic nephropathy. Coupled with their increased risk for cardiovascular disease, these individuals pose an enormous economic and social burden to all countries. This review will discuss therapeutic strategies, aimed at control of blood pressure and proteinuria, to prevent or retard the development of diabetic nephropathy. METHODS: Studies that involved patients with type 2 diabetes with albuminuria (microalbuminuria or proteinuria) and/or hypertension and/or renal impairment were included in this review. The PubMed Medline database was used as the source of data. RESULTS: Blood pressure control is paramount in reducing cardiovascular risk and the development of diabetic nephropathy. The target blood pressure is <130/80 mm Hg in all patients with type 2 diabetes. Angiotensin receptor blockers (ARBs) are the preferred first-line agents while angiotensin-converting enzyme (ACE) inhibitors can be considered in those with microalbuminuria and normoalbuminuria. Reduction in proteinuria retards the progression of nephropathy and should be considered as a goal on its own. Dual therapy with an ACE inhibitor and ARB can be considered in patients with severe proteinuria or uncontrolled hypertension. CONCLUSION: Important strategies to prevent or retard the progression of diabetic nephropathy in type 2 diabetes include excellent blood pressure control with an aggressive approach to reduce microalbuminuria or proteinuria. The drugs of choice are the ARB and the ACE inhibitor.