Can we effectively manage chronic kidney disease with a precision-based pharmacotherapy plan? Where are we?

ABSTRACT

Introduction

In recent years, thanks to significant advances in basic science and biotechnologies, nephrology has witnessed a deeper understanding of the mechanisms leading to various conditions associated with or causing kidney disease, opening new perspectives for developing specific treatments. These new possibilities have brought increased challenges to physicians, who face with a new complexity in disease characterization and selection the right treatment for individual patients.

Areas covered

We chose four therapeutic situations: anaemia in chronic kidney disease (CKD), heart failure in CKD, IgA nephropathy (IgAN) and membranous nephropathy (MN). The literature search was made through PubMed.

Expert opinion

Anaemia management remains challenging in CKD; a personalized therapeutic approach is often needed. Identifying patients who could benefit from a specific therapy is also an important goal for patients with CKD and heart failure with reduced ejection fraction. Several new treatments are under clinical development for IgAN; interestingly, they target specifically the pathogenetic mechanisms of the disease. The understanding of MN pathogenesis as an autoimmune disease and the discovery of several autoantibodies allows a better characterization of patients. High-sensible techniques for lymphocyte counting open the possibility of more personalized use of anti CD20 therapies.

KEYWORDS:

• Personalised medicine
• anaemia
• chronic kidney disease
• heart failure
• IgA nephropathy
• membranous nephropathy
• rituximab
• erythropoiesis stimulating agents
• HIF-PH inhibitors

Article highlights

• Many areas of Nephrology have seen significant improvements in the understanding of their pathophysiology and treatment options.

• The availability of a new class of oral drugs, the HIF-PH inhibitors, has increased the treatment options for anaemia in chronic kidney disease.

• Correct clustering of patients with heart failure and reduced ejection fraction is important for predicting patient outcome and selecting more appropriate treatment.

• The treatment of IgA nephropathy is a rapidly evolving field, with several new drugs becoming available that target the pathophysiology of the disease at different stages.

• The use of anti-PLA2R testing and high-sensitivity B-cell counts are important steps in personalizing the management of membranous nephropathy.

Declaration of interest

F Locatelli has been a member of Advisory Boards for Amgen, Astellas, Averoa and Da Vita and a speaker at meetings supported by Amgen, Astellas and Vifor Pharma.

E Paoletti acts as consultant for and received fees from AstraZeneca; VIFOR Pharma; Astellas; Novartis; GSK; Bayer.

M Ravera has been a member of advisory boards for Astellas and GSK; and an invited speaker at meetings supported by Amgen, Astellas, Vifor Pharma, Boehringer Ingelheim and AstraZeneca.

L Del Vecchio participated in Advisory Board meetings for Travere, and received speaker fees at meeting indirectly supported by Amgen, Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, Vifor Pharma.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.