What is the management for glomerulonephritis?

Management of Glomerulonephritis

The management of glomerulonephritis requires a disease-specific approach that addresses both the underlying cause and kidney manifestations, with therapy tailored to the specific type of glomerulonephritis, disease severity, and patient characteristics. 1

General Management Principles

• Treatment should address immediate disease morbidity with intensity based on presenting symptom severity and glomerulonephritis type 1
• Kidney biopsy is the gold standard for diagnosis and guides specific treatment selection 1, 2
• Select therapy that prevents disease progression, recognizing that complete clinical remission may not be possible in all forms of chronic glomerulonephritis 1
• Minimize harmful side effects from immunosuppression through careful monitoring and prophylactic measures 1

Supportive Care Measures

Blood Pressure and Proteinuria Management

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

Edema Management

• Restrict dietary sodium to <2.0 g/day to reduce edema, control blood pressure, and help manage proteinuria 4, 3
• Use diuretics as first-line agents for edema management 1, 4
• Add mechanistically different diuretics if response is insufficient 1
• Monitor for adverse effects of diuretics including hyponatremia, hypokalemia, GFR reduction, and volume depletion 1, 4

Dietary Management

• Adjust protein intake based on degree of proteinuria and kidney function 1
• For nephrotic-range proteinuria: 0.8-1 g/kg/day with additional protein to compensate for losses (up to 5 g/day) 1, 4
• For eGFR <60 ml/min/1.73 m² with nephrotic-range proteinuria: limit to 0.8 g/kg/day 1
• Avoid protein restriction <0.6 g/kg/day due to safety concerns and risk of malnutrition 1, 3

Disease-Specific Treatment Approaches

Infection-Related Glomerulonephritis

• For post-streptococcal GN: treat with penicillin (or erythromycin if penicillin-allergic) even in absence of persistent infection 1
• Manage nephritic syndrome with diuretics, antihypertensives, supportive care, and dialysis if necessary 1
• For severe crescentic post-streptococcal GN, consider corticosteroids based on anecdotal evidence 1

Membranous Nephropathy

• Consider observation for 6 months before initiating immunosuppressive therapy unless there are severe symptoms or declining kidney function 1, 3
• 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, 4
• Consider cyclosporine or tacrolimus for at least 6 months in patients with contraindications to cyclical corticosteroid/alkylating-agent regimens 1, 4

Focal Segmental Glomerulosclerosis (FSGS)

• For nephrotic syndrome due to FSGS, use high-dose corticosteroids for a minimum of 4 weeks, up to 16 weeks as tolerated 1, 3
• Taper corticosteroids slowly over 6 months after achieving complete remission 1, 4
• For steroid-resistant or steroid-intolerant cases, consider calcineurin inhibitors (cyclosporine or tacrolimus) 1, 4

Membranoproliferative Glomerulonephritis (MPGN)

• For adults or children with presumed idiopathic MPGN with nephrotic syndrome AND progressive decline of kidney function, use oral cyclophosphamide or MMF plus low-dose alternate-day or daily corticosteroids with initial therapy limited to less than 6 months 1, 5
• The term MPGN is being replaced with a mechanistic classification based on complement (Ig+C3 and Ig-C3) 5, 1
• Treatment should be based on identification of the underlying cause and may include immunosuppression, chemotherapy for monoclonal gammopathy disorders, or complement-regulatory therapies 5, 1

Minimal Change Disease (MCD)

• Use high-dose corticosteroids for initial treatment, tapered over a period of 4 weeks if complete remission is achieved, and for a maximum period of 16 weeks if complete remission is not achieved 5
• For patients with contraindications or intolerance to high-dose corticosteroids, use oral cyclophosphamide or calcineurin inhibitors 5
• Use the same initial dose and duration of corticosteroids for infrequent relapses 5

Viral Hepatitis-Associated GN

• For HCV-infected patients with CKD Stages 1 or 2 and GN, use combined antiviral treatment with pegylated interferon and ribavirin 5, 1
• For HCV-infected patients with CKD Stages 3,4, or 5 and GN not yet on dialysis, use monotherapy with pegylated interferon, with doses adjusted to kidney function 5, 1
• For HBV infection and GN, treat with interferon-α or nucleoside analogues as recommended for the general population 5, 1

Immunosuppression Safety Considerations

• Screen for latent infections prior to initiating immunosuppression 1, 3
• Monitor therapeutic drug levels where clinically indicated 1, 3
• Review vaccination status and update as required before starting immunosuppression 1, 3
• Consider fertility preservation where indicated 1, 4
• Monitor for development of cancers or infections during immunosuppressive therapy 1, 4
• Provide pneumococcal vaccine, influenza vaccine, and herpes zoster vaccination (Shingrix) 1, 4
• Consider prophylactic trimethoprim-sulfamethoxazole for patients receiving high-dose prednisone or other immunosuppressive agents 1, 4

Monitoring and Follow-up

• Assess proteinuria regularly - reduction in proteinuria is a marker of treatment response 1, 3
• Monitor for a ≥40% decline in eGFR from baseline over 2-3 years as a surrogate outcome measure for kidney failure 1, 3
• Perform repeat kidney biopsy only if the patient has rapidly deteriorating kidney function or if it will potentially alter the diagnosis or therapeutic plan 1

Common Pitfalls and Caveats

• IgA-dominant postinfectious GN needs to be distinguished from idiopathic IgA nephropathy to avoid inappropriate corticosteroid treatment 1
• Prolonged immunosuppression or multiple rounds of immunosuppression is associated with more toxic drug exposure over time 1
• The safety of protein restriction in glomerulonephritis has not been established in children 1
• Vigilant monitoring for side effects is warranted, irrespective of chosen therapy, with supportive care aimed at limiting ancillary damage from both nephrotic syndrome and immunosuppressive agents 5