Clinical Decision-Making About Immunosuppressive Treatment in Focal Segmental Glomerulosclerosis
Bibliographic record
Abstract
Rationale & Objective Focal segmental glomerulosclerosis (FSGS) is a heterogeneous disorder with a high risk of progression to kidney failure. There are no approved therapies for FSGS, and futility of treatment is poorly defined. The Cure Glomerulonephropathy (CureGN) study offers the opportunity to describe the characteristics of participants who started immunosuppressive therapy (IST), never received IST, or in whom this treatment was discontinued. Study Design An observational cohort. Settings & Participants Participants enrolled in CureGN with FSGS and surveyed nephrologists. Interventions The clinical and laboratory data from participants with FSGS who were enrolled in the CureGN observational cohort were reviewed to define features associated with withholding initial IST or terminating ongoing IST. Nephrologists were surveyed about what factors would influence their decision to prescribe or withdraw IST in patients with FSGS. Outcomes (1) Identify factors associated with IST initiation and discontinuation in individuals with FSGS; and (2) Identify clinical and laboratory features nephrologists consider when they recommend against the use of IST at diagnosis (initiation of care) and during the course of disease. Results Based on quantitative findings from the CureGN cohort and survey responses from practicing nephrologists, a low estimated glomerular filtration rate at presentation, significant glomerulosclerosis, and interstitial fibrosis and tubular atrophy on kidney biopsy make initiation of IST less likely. Limitations Heterogeneous nature of the cohort and an inability to divide the patients into KDIGO subgroups of FSGS. Rationale for decision to stop or defer treatment was not available. More surveys were completed by pediatric providers, and the majority were completed by academic practitioners. Conclusions The factors that impact decisions about IST initiation and discontinuation were consistent among pediatric and internal medicine nephrologists, namely advanced scarring and lower estimated glomerular filtration rate. We suggest that this information should be incorporated into patient management guidelines and clinical trial design. Plain Language Summary Patients with focal segmental glomerulosclerosis (FSGS) are at high risk for progression to kidney failure and there are no approved therapies. This study from the CureGN consortium described clinical situations in which immunosuppressive therapy (IST) was started, not started, or discontinued in participants with FSGS. Furthermore, we surveyed nephrologists to better understand factors that influence the management of patients with FSGS. Participants in the CureGN cohort with a lower estimated glomerular filtration rate and advanced scarring on kidney biopsy were less likely to be started on IST and have this treatment discontinued, which was similar to what surveyed providers did in practice. Understanding the characteristics of these patients may help further develop management guidelines and assist in clinical trial design.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".