From the Guidelines
The management of viral glomerulonephritis should primarily focus on treating the underlying viral infection with direct-acting antivirals (DAAs) for hepatitis C-related cases, and supportive care for kidney function, as recommended by the 2018 KDIGO clinical practice guideline 1.
Key Recommendations
- For hepatitis C-related glomerulonephritis, DAAs such as sofosbuvir/ledipasvir or glecaprevir/pibrentasvir are the standard of care, with rates of sustained virologic response (SVR) ranging from 74% to 83% and low adverse event rates 1.
- In cases with cryoglobulinemic flare, nephrotic syndrome, or rapidly progressive kidney failure, immunosuppressive agents with or without plasma-exchange should be used in addition to DAA treatment 1.
- Rituximab is recommended as the first-line immunosuppressive treatment for patients with histologically active HCV-associated glomerular disease who do not respond to antiviral therapy, particularly those with cryoglobulinemic kidney disease 1.
Supportive Care
- Blood pressure control using ACE inhibitors or ARBs to reduce proteinuria and slow disease progression.
- Diuretics for fluid overload and dietary sodium restriction (<2g/day) as needed.
- Regular monitoring of kidney function, proteinuria, and viral load to assess treatment response and adjust therapy accordingly.
Important Considerations
- Before initiating rituximab therapy, patients should be assessed for HBV infection to avoid fulminant hepatitis resulting from HBV reactivation 1.
- The potential to cure HCV infection with DAA treatment has shifted the focus from immunosuppression to HCV eradication as the first-line management approach for most patients 1.
From the Research
Management Approach for Viral Glomerulonephritis
The management of viral glomerulonephritis involves a combination of general measures and disease-specific treatment.
- General measures include the treatment of associated complications such as oedema, achievement of target blood pressure, and proteinuria reduction, as well as the prevention and treatment of associated complications 2.
- Disease-specific treatment may require specialist care and can involve antiviral therapy, which has been shown to be effective in promoting the clearance of hepatitis B e-antigen (HBeAg) and reducing proteinuria in patients with hepatitis B virus-associated glomerulonephritis 3, 4.
- The use of antiviral agents such as lamivudine and tenofovir has been reported to be effective in treating hepatitis B virus-related membranous glomerulonephritis and proteinuria 5.
- The diagnosis of glomerulonephritis is typically made through a kidney biopsy, which can help to identify the underlying cause and guide treatment 6.
Treatment Options
- Antiviral therapy is a key component of the management of viral glomerulonephritis, particularly in cases where the disease is associated with hepatitis B virus infection 3, 4.
- Corticosteroid treatment may also be used in some cases, although its effectiveness in reducing proteinuria and promoting HBeAg clearance is less clear 3.
- The choice of treatment will depend on the underlying cause of the glomerulonephritis, as well as the severity of the disease and the presence of any associated complications.