The first encouragement I originally had for attending IPNA came from my parents whom had just arrived back from Iguazu Falls last year – when I told them the conference was in Brazil I was promptly told to “buckle down and get the work done to go!” Needless to say, I didn’t phrase it quite like that in my PDP!
The conference itself was held in Foz de Iguazu, a small town near the falls, which largely exists to supply a town for the workers at the nearby dam and tourists for the falls – there was not a lot else left to do – however, the academic work both on display and presented was excellent, and for a junior GRID trainee I learnt a tremendous amount.
I was fortunate enough to present two posters. The first was a case report on a complex patient who had a PD catheter migration soon post renal transplant presenting with minimal signs. Literature is slightly divided on when PD catheters should be removed, with some adult series suggesting at the time of transplantation to others up to 16 weeks later. Our learning point was that in an immunocompromised child signs can be subtle and that complications can occur outside of the immediate post-transplant period.
The other poster presented our center’s data on Rituximab use in frequently relapsing steroid sensitive nephrotics and steroid dependent patients. In our center we use a single dose of 375mg/m2 and then watch and wait to see the response. All of our patients had good B-cell depletion with the single dose and the response following this was both varied and interesting. 4 out of 20 patients remain in remission (median follow up period 734 days) and off steroids. What we found interesting were the other patients who had variable responses to B-cell repopulation. We had 3 patients in whom relapses followed B-cell repopulation – but with a median time lag of 203 days. A number of other patients either were given 2nd doses prophylactically or relapsed as soon as their B-cell numbers repopulated. Of the fifteen patients who didn’t get a prophylactic second dose the six-month chance of remaining in remission was 86.7% which is comparable to studies that use a higher dose. The differences in the patient groups can’t be easily explained by biopsy results, or other factors. This links in neatly to the presentation given by Professor Saleem during IPNA about the molecular reclassification of the nephrotic syndrome – splitting those into single gene, those with circulating factors and those with other mechanisms. Looking at our patient group it is clear to see there must be factors involved that, as yet, aren’t easily explained in order to rationalise the difference in B-cell repopulation that is seen.
I had some interesting conversations during conference – ranging from a physician in Boston asking for the blood of the 4 patients from our data set who have remained in remission after 1 dose, to starting to organise the joint French-British trainee night out in Paris with one of the French trainees! It was also interesting to talk to medics from non-NHS countries and hear about the genuine decision making that occurs secondary to cost – although we aim to cost save in England – we are lucky that our primary decision making is not always money driven – the NHS does have its good qualities!
Some key educational notes I made during the conference included the ASSESS-AKI study that, alongside other similar studies, shows the importance of long term nephrology follow up in patients who have had AKI – 16% of patients in this study having albuminuria at 3-5yr follow up. Balancing this “ideal” against healthcare planning is an interesting dilemma and was debated following the presentation – with some suggesting that if 1yr post AKI there is a normal eGFR, no proteinuria and a normal BP could the longer term follow up be with primary care?
Another trial that interested me was the ESCORT trial, which presented its preliminary data showing that targeting <50th centile rather than <95th centile post transplantation had no significant change in graft function, proteinuria or left ventricular mass index. The caveat to this is the low patient numbers (21) and still early data – however it is interesting that being overly aggressive in targeting BP may not be as worthwhile beyond the 95th centile as had been previously postulated. Full data is awaited.
Sessions on phosphate metabolism in CKD and tubular disorders were interesting and followed a similar pattern for me – seem logical and sensible when reading/hearing about it – but over the following weeks become more blurred and harder to recall without revision!
The nephrotic syndrome session was well attended which suggested long taper of initial steroid use doesn’t provide superior outcomes compared with 2-3 months (PREDNOS outcome interestingly awaited!) One speaker, suggested, based upon data from his group that we may reach a point where Rituximab is used as second or third line ahead of other drugs such as tacrolimus although the data to back this up is still awaited. New therapies such as Ofatumimab in SRNS showed some early promising results.
There was an interesting debate between differing opinions in the UTI session. The RIVUR study showed prophylaxis reduced UTI, but didn’t dramatically reduce scarring to a significant level. This was debated following the CUTIE study talk in which one side suggested prophylaxis does reduce UTIs and the morbidity associated with this, whereas others argued that it would require a significant number of patients needed to treat with antibiotics in order to prevent scarring – is this not the more important endpoint?
I attended the session on new therapies in SLE nephritis with hope considering some difficult patients we have been looking after recently – but, despite a number of new “imambs” – there doesn’t seem to be a significant step forward, with some studies showing harm with newer therapies.
The gala dinner was well attended on the Thursday and good fun – but the definite highlight outside of the conference were the falls – simply a breathtaking display of natural beauty and power – made the 27 hour journey home just about worth it!
Drew Maxted, Sep 2016