Jonathan Barratt, PhD, FRCP: We've talked a lot about biopsy, and of course, we need a biopsy, and we need nephrologists to know to do a biopsy. In your experience, certainly in the United States, when we think about community nephrologists and those that work in academic centers, what are the barriers to being able to perform a kidney biopsy?

Anuja Java, MD: That's a very important point, and something that as a nephrology community have been discussing from the standpoint of how much do we train our fellows into doing kidney biopsies? What is going to happen when they go out in the community? At this point, we do see a difference between what is happening in the community and academic centers. As we said, kidney biopsy is an invasive procedure, so when you're looking at a community nephrologist, they might, number one, they don't do it themselves. They're dependent on a radiologist, a technician who must do it for them. They may think of it if they don't have a trained radiologist who's going to do it, and it's been here since they did it themselves, a patient may not end up getting a biopsy. It's a liability issue. It's an invasive procedure. They may not do it. The other issue may be that in community programs, if they don't have a collaboration or a communication with a good renal pathologist, and even if they did a biopsy and they're not able to get the results that they're looking for, and the outcome is going to be no different, whether they did or they didn't do, then that may deter a lot of community nephrologists from going in and doing a biopsy. Those are definitely issues that differ and that are a hindrance for a community nephrologist going in and doing a biopsy. Then of course, that leads to not recognizing these diseases on time and not treating them on time brings us back to the issue that we discussed earlier.

Jonathan Barratt, PhD, FRCP: That's understandable in an area where we haven't had the therapies, we have potentially becoming available to manage these patients. But what I think is becoming more important is the fact that we are now understanding people are living with these glomerular diseases for the rest of their life. We need to start to think about lifetime risk of kidney failure, not just what's going to happen in the next five or ten years and we can only treat a disease if we know what the disease is. From what we've discussed already, we don't have biomarkers to be able to help us make those diagnoses. Certainly not to the extent that would allow us to give a new therapy or to offer a patient the opportunity to go into a clinical trial.

Transcript Edited for Clarity