Therapeutic variability in adult minimal change disease and focal segmental glomerulosclerosis.
BACKGROUND
Variability in the management of glomerulonephritis may negatively impact efficacy and safety. However, there are little/no data on actual variability in the treatment of minimal change disease (MCD)/focal segmental glomerulosclerosis (FSGS) in adults. We assessed Spanish practice patterns for the management of adult nephrotic syndrome due to MCD or FSGS. The absence of reasonably good evidence on treatment for a disease often increases the variability substantially. Identification of evidence-practice gaps is the first necessary step in the knowledge-to-action cyclical process. We aim to analyse the real clinical practice in adults in hospitals in Spain and compare this with the recently released Kidney Disease: Improving Global Outcomes clinical practice guideline for glomerulonephritis.


METHODS
Participating centres were required to include all adult patients (age >18 years) with a biopsy-proven diagnosis of MCD or FSGS from 2007 to 2011. Exclusion criteria included the diagnosis of secondary nephropathy.


RESULTS
We studied 119 Caucasian patients with biopsy-proven MCD (n = 71) or FSGS (n = 48) from 13 Spanish hospitals. Of these patients, 102 received immunosuppressive treatment and 17 conservative treatment. The initial treatment was steroids, except in one patient in which mycophenolate mofetil was used. In all patients, the steroids were given as a single daily dose. The mean duration of steroid treatment at initial high doses was 8.7 ± 13.2 weeks and the mean global duration was 38 ± 32 weeks. The duration of initial high-dose steroids was <4 weeks in 41% of patients and >16 weeks in 10.5% of patients. We did find a weak and negative correlation between the duration of whole steroid treatment in the first episode and the number of the later relapses (r = -0.24, P = 0.023). There were 98 relapses and they were more frequent in MCD than in FSGs patients (2.10 ± 1.6 versus 1.56 ± 1.2; P = 0.09). The chosen treatment was mainly steroids (95%). Only seven relapses were treated with another drug as a first-line treatment: two relapses were treated with mycophenolate and five relapses were treated with anticalcineurinics. A second-line treatment was needed in 29 patients (24.4%), and the most frequent drugs were the calcineurin inhibitors (55%), followed by mycophenolate mofetil (31%). Although cyclophosphamide is the recommended treatment, it was used in only 14% of the patients.


CONCLUSIONS
We found variation from the guidelines in the duration of initial and tapered steroid therapy, in the medical criteria for classifying a steroid-resistant condition and in the chosen treatment for the second-line treatment. All nephrologists started with a daily dose of steroids as the first-line treatment. The most frequently used steroid-sparing drug was calcineurin inhibitors. Cyclophosphamide use was much lower than expected.
Department of Nephrology , Hospital Universitario Fundación Alcorcón , calle Budapest 1, Alcorcón, Madrid , Spain.
Gema
G
Fernandez-Juarez
Department of Nephrology , Hospital Universitario Fundación Alcorcón , calle Budapest 1, Alcorcón, Madrid , Spain.
Javier
J
Villacorta
Department of Nephrology , Hospital Ramón y Cajal , Madrid , Spain.
Gloria
G
Ruiz-Roso
Department of Nephrology , Hospital General Universitario Gregorio Marañon , C/Doctor Esquerdo 46, Madrid , Spain.
Nayara
N
Panizo
Department of Nephrology , Hospital Universitario Fundación Alcorcón , calle Budapest 1, Alcorcón, Madrid , Spain.
Isabel
I
Martinez-Marín
Department of Dialysis , Fundacio Puigvert , Barcelona , Spain.
Helena
H
Marco
Department of Nephrology , Hospital Clinico , c/Villarroel 170, Barcelona , Spain.
Pilar
P
Arrizabalaga
Department of Nephrology , Fundació Puigvert , Barcelona , Spain.
Montserrat
M
Díaz
Department of Nephrology , Fundacion Jimenez Días , Madrid , Spain.
Vanessa
V
Perez-Gómez
Department of Nephrology , Hospital Universitario La Paz , Madrid , Spain.
Marco
M
Vaca
Department of Nephrology , Hospital del Mar , Barcelona , Spain.
Eva
E
Rodríguez
Department of Nephrology , Hospital Lucus Augusti Ulises Romero , Lugo , Spain.
Carmen
C
Cobelo
Department of Nephrology , Hospital Universitario Principe de Asturias , Alcala de Henares, Madrid , Spain.
Loreto
L
Fernandez
Department of Nephrology , Dr Peset Hospital , Avda Gaspar Aguilar, 90, 46027 Valencia , Spain.
Ana
A
Avila
Department of Nephrology , Hospital 12 de Octubre , Carretera de Andalucia, km 5,400, Madrid , Spain.
Manuel
M
Praga
Department of Nephrology , Hospital Ramón y Cajal , Madrid , Spain.
Carlos
C
Quereda
Fundacion Jimenez Diaz , Universidad Autonoma, Unidad de Dialisis , Av. Reyes Catolicos 2, Madrid , Spain.
Alberto
A
Ortiz
clinical practice variability; glomerulonephritis; immunosuppression