3 Things to Know About Glomerular Disease

Gabriel Cara Fuentes, MD, PhD, offers insights for physicians regarding pediatric glomerular disease treatment and referral.

Gabriel Cara Fuentes, MD, PhD, a pediatric nephrologist and principal investigator at the Kidney and Urinary Tract Research Center at Nationwide Children’s Hospital, is focused on a translational approach to improving pediatric care and outcomes. Since arriving at Nationwide Children’s in January 2024, he has utilized his nephrological expertise in patient care and collaborated with other kidney specialists. He is also the director of the Glomerular Disease Clinic.

What should primary care physicians know about glomerular disease and its impact on children? When should they refer to a specialist?

Glomerular diseases are very common and represent a leading cause of chronic kidney disease and end-stage kidney disease in children. The clinical presentation can vary a lot across diseases and among patients, so it is key for primary care physicians to be very familiar with the classic clinical manifestations as well as early diagnostic and therapeutic approaches. While there are some cases of self-limited and mild glomerular diseases, some cases require urgent hospitalization and treatment. So, primary care physicians should be able to recognize red flags in the clinical history, physical exam, and/or laboratory findings to determine the best next step for that patient. In this way, it is also important to reach out for help or consultation when there are doubts.

Referral depends somewhat on the comfort level of the pediatrician. Glomerular diseases often present with either blood and/or proteins in the urine, with or without hypertension or kidney dysfunction. But other conditions can present similarly, like urinary tract infections, kidney stones or kidney cysts. Therefore, it is very important to integrate information from clinical history, physical exams, and laboratory. I would recommend referring a patient to nephrology if there is evidence of blood and/or protein in the urine that is thought to come from the kidney, and particularly if there are red flags like swelling, systemic manifestations (rash, changes in weight, etc.), hypertension, persistent abnormalities in urinalysis, etc.

What’s the most important thing for nephrologists to consider when caring for children with this condition?

From my standpoint, I think it is key to listen to our patients and their families. Each individual and family experiences the disease, treatments and uncertainties in a particular way. Understanding our patients will help facilitate communication between doctors, patients and families and ultimately will improve patient care and trust. This is particularly important when we talk about glomerular diseases because there is still a lot we do not know, and because, despite current therapies, patients often suffer progression of their kidney disease or important complications along the way.

For families, their child was healthy one day, but the next day showed up with extreme swelling or blood in the urine, so there is a lot of uncertainty and stress. So, it is key to connect with family and build a trusting relationship. This usually requires time, so it is essential to dedicate a significant amount of time to these patients and families to try to educate and provide reliable resources for them to continue learning along the way.

How does a glomerular disease clinic, such as the one at Nationwide Children’s, benefit children?

The idea of the glomerular disease clinic is to provide multidisciplinary care. While these diseases primarily involve the kidney filters, many patients suffer from many comorbidities secondary to the kidney disease itself or to the therapies used to treat the kidney disease. Thus, many patients struggle with nutrition, mental health, etc.  The clinic combines providers with expertise in the diagnosis and management of glomerular diseases as well as clinical and translational research, but also access to providers from other disciplines such as psychology, nutrition specialists, social workers and research.

Research is key to improving care for children with glomerular diseases. Over the last few years, there has been great improvement in our understanding and treatment of certain glomerular diseases. Unfortunately, most clinical studies, particularly those testing newer therapies, remain restricted to adults. Thus, there is a need to better understand the disease pathogenesis in children and explore new therapies that are more effective and safer to ultimately improve patient care. Likewise, we are working to develop tools to help us individualize care. This is essential because the same disease may behave very differently across children. Thus, our goal is to provide the best possible patient care and facilitate access to clinical trials, research and resources important for patients and their families.