What is the management of post-glomerulonephritis?

Management of Post-Glomerulonephritis

The management of post-glomerulonephritis primarily consists of supportive care, including diuretics, sodium restriction, and blood pressure control with ACE inhibitors or ARBs, while immunosuppressive therapy is reserved for specific cases with severe or progressive disease. 1

General Management Principles

Supportive Care

• Restrict dietary sodium to <2.0 g/day to reduce edema, control blood pressure, and help manage proteinuria 1
• Use diuretics as first-line agents for edema management, adding mechanistically different diuretics if response is insufficient 1
• Monitor for adverse effects of diuretics including hyponatremia, hypokalemia, GFR reduction, and volume depletion 1
• Adjust protein intake based on degree of proteinuria and kidney function:
  • For nephrotic-range proteinuria: 0.8-1 g/kg/day with additional protein to compensate for losses (up to 5 g/day) 1
  • For eGFR <60 ml/min/1.73 m² with nephrotic-range proteinuria: limit to 0.8 g/kg/day 1

Blood Pressure Management

• Use ACE inhibitors or ARBs at maximally tolerated doses as first-line therapy for patients with both hypertension and proteinuria 1, 2
• Target systolic blood pressure <120 mmHg in most adult patients using standardized office BP measurement 1
• In children, target 24-hour mean arterial pressure at ≤50th percentile for age, sex, and height by ambulatory blood pressure monitoring 1
• Consider nifedipine for acute hypertension control 3
• Hold RAS inhibitors during intercurrent illnesses with risk of volume depletion 1

Infection Prevention

• Administer pneumococcal vaccine to patients with glomerular disease and nephrotic syndrome 1
• Ensure patients and household contacts receive influenza vaccine 1
• Provide herpes zoster vaccination (Shingrix) 1
• Consider prophylactic trimethoprim-sulfamethoxazole for patients receiving high-dose prednisone or other immunosuppressive agents 1
• Screen for tuberculosis, hepatitis B, hepatitis C, HIV, and syphilis in clinically appropriate patients 1

Specific Management Based on Disease Type and Severity

Acute Post-Streptococcal Glomerulonephritis

• Treatment is primarily supportive care with diuretics and antihypertensive therapy 4
• Most patients make a full recovery without specific immunosuppressive therapy 4, 3
• Monitor for complications such as hypertensive emergencies, congestive cardiac failure, nephrotic syndrome, and severe acute kidney injury 4

Membranous Nephropathy

• Consider observation for 6 months before initiating immunosuppressive therapy unless there are severe symptoms or declining kidney function 1
• For patients requiring immunosuppression, use a 6-month course of alternating monthly cycles of oral and IV corticosteroids with oral alkylating agents (cyclophosphamide preferred over chlorambucil) 1
• Adjust doses of cyclophosphamide or chlorambucil according to patient age and eGFR 1
• Consider cyclosporine or tacrolimus for at least 6 months in patients who cannot receive or have contraindications to cyclical corticosteroid/alkylating-agent regimens 1

Focal Segmental Glomerulosclerosis (FSGS)

• For nephrotic syndrome due to FSGS, consider high-dose corticosteroids for a minimum of 4 weeks, up to 16 weeks as tolerated 1
• Taper corticosteroids slowly over 6 months after achieving complete remission 1
• For steroid-resistant or steroid-intolerant cases, consider calcineurin inhibitors (cyclosporine or tacrolimus) 1

Monitoring and Follow-up

• Assess proteinuria regularly - goals for reduction vary among different types of glomerular disease 1
• Monitor for a ≥40% decline in eGFR from baseline over 2-3 years as a surrogate outcome measure for kidney failure 1
• Perform repeat kidney biopsy only if:
  • The patient has rapidly deteriorating kidney function (doubling of serum creatinine over 1-2 months) 1
  • There is diagnostic uncertainty 4
  • The disease shows atypical progression 5
• Watch for persistent proteinuria, hypertension, and progression to chronic kidney disease which may require long-term monitoring 4, 6

Special Considerations

Immunosuppression Safety

• Screen for latent infections prior to initiating immunosuppression 1
• Monitor therapeutic drug levels where clinically indicated 1
• Review vaccination status and update as required before starting immunosuppression 1
• Consider fertility preservation where indicated 1
• Monitor for development of cancers or infections during immunosuppressive therapy 1

Poor Prognostic Factors

• Persistence of nephrotic state, hypertension, and renal insufficiency following an acute attack 6
• Presence of glomerular crescents on renal histology 6
• Rapidly progressive glomerulonephritis may require more aggressive intervention 7