What is the management plan for chronic glomerulonephritis?

Management of Chronic Glomerulonephritis

The management of chronic 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

Diagnostic Evaluation

• Kidney biopsy remains the "gold standard" for diagnostic evaluation of glomerular diseases 2
• Repeat kidney biopsy should be performed only if it will potentially alter the diagnosis, therapeutic plan, or contribute to the estimation of prognosis 2
• Assess total urinary protein excretion with a 24-hour urine collection in adults; first morning protein-creatinine ratio (PCR) is more appropriate in children 2
• Use CKD-EPI creatinine equation to assess eGFR in adults and modified Schwartz equation in children 2
• Perform routine evaluation of urine sediment for erythrocyte morphology and the presence of red cell casts and/or acanthocytes 2

Treatment Principles

• Choose a treatment regimen that averts immediate morbidity of the primary disease process 2
• The intensity of induction therapy should be based on the severity of presenting symptoms and type of glomerulonephritis 2
• Complete clinical remission may not be possible in all forms of chronic glomerulonephritis 2
• Prolonged immunosuppression or multiple rounds of immunosuppression may be required to prevent or delay CKD progression 2
• Proteinuria reduction is a surrogate endpoint in the treatment of glomerulonephritis 2

Supportive Care

Blood Pressure Management

• Use ACE inhibitors or ARBs at maximally tolerated doses as first-line therapy for patients with both hypertension and proteinuria 1
• 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 1
• Hold RAS inhibitors during intercurrent illnesses with risk of volume depletion 1
• Hypertension in chronic GN is primarily volume dependent, not necessarily related to deterioration of renal function 3

Edema Management

• Restrict dietary sodium to <2.0 g/day to reduce edema, control blood pressure, and help manage proteinuria 2, 1
• Use diuretics as first-line agents for edema management 2
• Add mechanistically different diuretics if response is insufficient 2
• Monitor for adverse effects of diuretics including hyponatremia, hypokalemia, GFR reduction, and volume depletion 2

Dietary Management

• Adjust protein intake based on degree of proteinuria and kidney function 2:
  • For nephrotic-range proteinuria: 0.8-1 g/kg/day with additional protein to compensate for losses (up to 5 g/day) 2
  • For eGFR <60 ml/min/1.73 m² with nephrotic-range proteinuria: limit to 0.8 g/kg/day 2
• Restrict dietary fats in patients with elevated serum cholesterol 2
• Target caloric intake 35 kcal/kg/day; for eGFR <60 ml/min/1.73 m²: 30-35 kcal/kg/day 2

Immunosuppressive Therapy

• Immunosuppression is reserved for specific types of glomerulonephritis and cases with severe or progressive disease 1, 4
• Traditional immunosuppressive regimens include glucocorticoids, cyclosporine A, mycophenolate mofetil, cyclophosphamide, and azathioprine 4
• For severe forms of glomerulonephritis, rituximab represents a newer and less toxic alternative to cyclophosphamide 4
• When using mycophenolate mofetil, the recommended dose for renal transplant patients is 1 g administered orally twice a day 5
• Adjust doses of immunosuppressants according to patient age and eGFR 1

Safety Considerations for Immunosuppression

• 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
• If neutropenia develops (ANC < 1.3 x 10³/µL), interrupt or reduce the dose of mycophenolate mofetil 5
• Mycophenolate mofetil is associated with increased risks of first trimester pregnancy loss and congenital malformations 5

Monitoring and Follow-up

• Assess proteinuria regularly - reduction in proteinuria is a marker of treatment response 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 1

Disease-Specific Considerations

IgA Nephropathy

• The primary focus of management should be optimized supportive care 2
• Assess cardiovascular risk and commence appropriate interventions 2
• Give lifestyle advice, including information on dietary sodium restriction, smoking cessation, weight control, and exercise 2
• Variant forms of IgAN (IgA deposition with minimal change disease, IgAN with acute kidney injury, and IgAN with rapidly progressive glomerulonephritis) may require specific immediate treatment 2

Common Pitfalls and Caveats

• Avoid protein restriction <0.6 g/kg/day due to safety concerns and risk of malnutrition 2
• The safety of protein restriction in GN has not been established in children 2
• Avoid combining ACE inhibitors and ARBs except in cases of persistently high proteinuria 4
• Patients with chronic GN become salt sensitive as renal damage progresses, making sodium restriction increasingly important 3
• Overactivity of the sympathetic nervous system contributes to hypertension in chronic GN, which may require additional antihypertensive medications 3
• Combination of a RAAS blockade with a calcium channel blocker and a diuretic may be effective in attaining target BP and reducing proteinuria 3