Glomerular and Vascular Disorders
17 cases on pharmacologic decisions across glomerular disease, ANCA and other renal vasculitides, thrombotic microangiopathies, and renovascular disease — immunosuppression and novel-agent selection, plasma exchange and complement blockade timing, and treating a kidney whose autoimmune or vascular process may not be fully reversible — choose a case below to open its full multi-voice debate.
A single patient, newly biopsied with membranous nephropathy and a high anti-PLA2R titer. The disagreement isn't whether to treat — it's whether a real trial result favoring the harsher regimen should change the reflexive first choice.
A single patient, six months into maximized supportive care for IgA nephropathy with proteinuria that won't come down further. The disagreement is whether a trial that argued against added therapy has been overtaken by a drug it never tested.
A single patient, newly diagnosed with class IV lupus nephritis. The disagreement isn't whether to add a second agent to mycophenolate — three current guidelines already agree on that — it's which one, for reasons that don't fully agree with each other.
A single patient, three weeks into a rapidly progressive renal decline from newly diagnosed GPA. No trial cleanly favors one induction agent over the other for a case this severe — that absence of a clean answer is the actual disagreement.
A single patient, just started on standard AAV induction. The disagreement isn't whether steroid-sparing is worth pursuing — it's whether the drug built for it still has an evidence base to stand on, and what to do in the meantime.
A single patient in his fourth relapse of minimal change disease, three of them inside two years, with real accumulated steroid toxicity. The disagreement is which steroid-sparing agent actually buys him treatment-free years, not just another remission.
A single patient with FSGS and real, already-present chronic scarring. The disagreement is whether immunosuppression still earns its toxicity once meaningful scarring exists, or whether a newer non-immunosuppressive drug with an unproven long-term benefit is the more honest choice.
A single patient whose C3 glomerulopathy has already failed one traditional regimen. The disagreement is whether a complement-targeted drug should be the next step, or whether traditional therapy simply wasn't given a full enough trial yet.
A single patient with albumin low enough, and an added immobility risk, to make prophylactic anticoagulation a real question rather than a formality. The disagreement is whether two independent risk factors should be treated as one open-ended decision or two separately timed ones.
A single patient, three weeks postpartum, with a working diagnosis of atypical HUS and a genetic panel still pending. The disagreement is whether to commit to complement inhibition on clinical suspicion alone or start with the older, cheaper therapy while confirmation is awaited.
A single patient, hours into emergent plasma exchange for TTP with neurologic involvement. The disagreement isn't whether caplacizumab works — a real trial already showed that — it's whether its named bleeding cost is worth paying before the underlying disease treatment has had time to act.
A single patient, dialysis-dependent at diagnosis with near-complete crescents on biopsy. The disagreement is whether treatment intensity should be set by the historic recovery odds at this severity, or by what the treatment is actually protecting against.
A single patient with unilateral renal artery stenosis and new proteinuria who needs a RAAS inhibitor for exactly what his kidneys can no longer be assumed to tolerate without watching closely. The disagreement is whether the anatomic risk should be avoided or simply monitored.
A single patient in acute scleroderma renal crisis, where the usual instinct to avoid RAAS blockade during rising creatinine is inverted. The disagreement is how fast to push the one drug that's actually disease-modifying, not whether to use it.
A single patient in partial remission on immunosuppression whose proteinuria has stopped moving. The disagreement is less about whether an SGLT2 inhibitor could help than about what, specifically, it's actually being asked to do.
A single patient, five months into a kidney transplant, whose immunosuppression has become the thing threatening the graft it was meant to protect. The disagreement is how much of the response to build in now versus wait to see.
A single patient with newly active renal involvement from longstanding, untreated hepatitis C. The disagreement is whether treating the viral driver first is still the right sequence once the vasculitis has become organ-threatening.