An overview of immunosuppressive therapy in idiopathic membranous nephropathy.

Idiopathic membranous nephropathy is the most common cause of nephrotic syndrome. In patients who present with nephrotic range proteinuria the clinical course is variable, with 50% of patients developing end stage renal disease after extended follow-up without therapy. We review the various immunosuppressive treatment modalities. The efficacy of alkylating agents is demonstrated in randomized trials, although side effects are a major drawback. Calcineurin inhibitors, rituximab and possibly adrenocorticotropic hormone (ACTH) are able to induce remission of proteinuria, which portends a good prognosis. However, the efficacy of these agents must be confirmed in randomized trials with adequate renal end points. Immunosuppressive treatment should be restricted to high risk patients. The use of immunosuppressive therapy has improved outcome of patients with iMN, with nowadays less than 10% of patients progressing to end stage renal disease (ESRD).

Anti-PLA2R antibodies in membranous nephropathy: ready for routine clinical practice?

The identification of circulating autoantibodies against the M-type phospholipase A2 receptor (anti-PLA2R) in patients with idiopathic membranous nephropathy (iMN) has been a major discovery. Anti-PLA2R can be measured by a commercially available test. It is suggested that measurement of anti-PLA2R will change the diagnostic strategy in patients with nephrotic syndrome and may guide treatment in patients with iMN. We review the available evidence and caution against the immediate injudicious use of the assay in routine clinical practice.

Oscillometric blood pressure measurements: differences between measured and calculated mean arterial pressure.

Mean arterial pressure (MAP) is often used as an index of overall blood pressure. In recent years, the use of automated oscillometric blood pressure measurement devices is increasing. These devices directly measure and display MAP; however, MAP is often calculated from systolic blood pressure (SBP) and diastolic blood pressure (DBP) as displayed by the device. In this study we have analysed measured and calculated MAP, obtained by two different oscillometric BP measurement devices in two different patient cohorts. The first cohort included 242 healthy subjects (male 40.5%, 50+/-13 years). BP measurements were performed with a Welch Allyn 5300P device. We found a small but significant difference between measured MAP and calculated MAP (MAP(m-c:) -1.8 mmHg, range -5.7 to 12.9 mmHg, p < 0.001). MAP(m-c) showed a significant, but weak correlation with DBP and SBP. The second cohort included included 134 patients with glomerular diseases (male 63%, 50+/14 years). BP measurements were performed with a Dinamap 487210 device. In this group we also observed a small difference between measured MAP and calculated MAP (+1.7 mmHg, range -15.3 to 28.2 mmHg, p<0.001). MAP (m-c) correlated with age, all blood pressure indices and heart rate. An overall analysis showed that age, SBP, DBP, and type of device are all independently related to MAP (m-c). There is a significant difference between measured and calculated MAP. The difference is small on average; however, this MAP(m-c) can be large in the individual patient. Moreover, there are differences of reported MAP between devices. Our data suggest that calculated and measured MAP cannot be used interchangeably.