What is the initial treatment approach for patients diagnosed with glomerulonephritis (inflammation of the glomeruli)?

Initial Treatment Approach for Glomerulonephritis

The initial treatment approach for glomerulonephritis should be corticosteroids, specifically prednisone or prednisolone at a daily single dose of 1 mg/kg (maximum 80 mg) or alternate-day dose of 2 mg/kg (maximum 120 mg). 1

Diagnostic Evaluation Before Treatment

Before initiating treatment, the following evaluations are essential:

• Kidney biopsy to determine the specific type of glomerulonephritis 1
• Assessment of kidney function through GFR or eGFR measurement 1
• Quantification of urine protein excretion 1
• Evaluation for underlying causes (infectious, autoimmune, etc.) 1

Treatment Algorithm Based on GN Type

Primary/Idiopathic Glomerulonephritis:

1. Initial Corticosteroid Therapy:

   • Prednisone/prednisolone at 1 mg/kg/day (maximum 80 mg) or 2 mg/kg alternate days (maximum 120 mg) 1
   • Continue high-dose corticosteroids for minimum 4 weeks if complete remission achieved 1
   • If no complete remission, continue for maximum 16 weeks as tolerated 1
   • After remission, taper slowly over 6 months 1

2. For patients with contraindications to high-dose steroids (diabetes, psychiatric conditions, severe osteoporosis):

   • Consider calcineurin inhibitors (CNIs) as first-line therapy 1
   • Cyclosporine (3-5 mg/kg/day) or tacrolimus (0.05-0.1 mg/kg/day) in divided doses 1

3. For steroid-resistant cases:

   • CNIs should be continued for minimum 6 months 1
   • If at least partial remission achieved by 6 months, continue CNIs for minimum 12 months 1
   • Consider adding low-dose corticosteroid therapy with CNI therapy 1

4. Additional therapies for refractory cases:

   • Consider mycophenolate mofetil (MMF) 500-1000 mg twice daily for 1-2 years 1
   • For frequently relapsing cases, consider cyclophosphamide 2-2.5 mg/kg/day for 8 weeks 1

Infection-Related Glomerulonephritis:

1. Post-streptococcal GN:

   • Treat with penicillin (or erythromycin if penicillin-allergic) even if no persistent infection 1
   • Manage nephritic syndrome with diuretics, antihypertensives, and supportive care 1
   • Corticosteroids only for severe crescentic GN based on anecdotal evidence 1

2. Infective endocarditis-related GN:

   • Antibiotic treatment for 4-6 weeks 1
   • Supportive care for kidney manifestations 1
   • Note that hematuria, proteinuria, and azotemia may persist for months despite treatment 1

3. IgA-dominant postinfectious GN (often associated with Staphylococcus/MRSA):

   • Appropriate antibiotic therapy 1
   • Avoid corticosteroids as this variant needs to be distinguished from idiopathic IgA nephropathy 1

Hepatitis-Related Glomerulonephritis:

1. HCV-associated GN:
   • For CKD stages 1-2: Combined antiviral treatment with pegylated interferon and ribavirin 1
   • For CKD stages 3-5 (not on dialysis): Monotherapy with pegylated interferon with dose adjustments 1
   • For cryoglobulinemia with nephrotic proteinuria: Consider plasmapheresis, rituximab, or cyclophosphamide with IV methylprednisolone and antiviral therapy 1

Supportive Therapy for All Types of GN

• ACE inhibitors or ARBs for proteinuria control 1, 2
• Blood pressure control targeting <130/80 mmHg 2
• Regular monitoring of kidney function and proteinuria every 3-6 months 2
• Low-protein diet may help prevent progression of chronic GN 3

Treatment Efficacy Monitoring

• Monitor for reduction in proteinuria (target <0.5-1 g/day) 2
• Regular assessment of kidney function (serum creatinine, eGFR) 2
• For patients on immunosuppressive therapy, monitor for side effects and adjust dosing as needed 1

Common Pitfalls and Caveats

• Not accounting for the lag between treatment initiation and reduction in proteinuria can lead to premature treatment changes 2
• Immunosuppressive therapy should not be initiated in patients with advanced kidney disease (eGFR ≤30 ml/min/1.73 m²) and small echogenic kidneys as risks outweigh benefits 2
• For secondary forms of GN, treating the underlying cause is essential before considering immunosuppression 1
• IgA-dominant postinfectious GN should not be treated with corticosteroids as it is most common in elderly and diabetics and associated with poor renal outcomes 1

Special Considerations

• Limited steroid therapy in children with membranoproliferative GN type I has shown promising results 4
• Early therapy with corticosteroids and control of associated hypertension may forestall progressive renal insufficiency in children with MPGN type I 4
• For MPGN with nephrotic syndrome and progressive decline in kidney function, consider oral cyclophosphamide or MMF plus low-dose alternate-day or daily corticosteroids for less than 6 months 1