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 antiviral medications for hepatitis B-associated cases, while providing supportive care for kidney function, as recommended by the 2018 KDIGO clinical practice guideline 1.
Key Recommendations
- For hepatitis C-related viral glomerulonephritis, DAAs such as sofosbuvir/ledipasvir or glecaprevir/pibrentasvir are recommended as the first-line treatment 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 DAAs 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 is essential to reduce proteinuria and slow kidney disease progression.
- Fluid and electrolyte management, including sodium restriction, is crucial for patients with edema or hypertension.
- Regular monitoring of kidney function through serum creatinine, estimated GFR, and urinalysis every 1-3 months is necessary to adjust treatment as needed.
Rationale
The approach to managing viral glomerulonephritis has evolved with the efficacy of DAAs in eradicating HCV infection, leading to improved kidney outcomes and quality of life 1. By prioritizing the treatment of the underlying viral infection and providing supportive care, clinicians can effectively manage viral glomerulonephritis and improve patient outcomes.
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.