What is the management plan for chronic glomerulonephritis?

Management of Chronic Glomerulonephritis

The management of chronic glomerulonephritis requires a disease-specific approach combining aggressive supportive care with selective immunosuppression, prioritizing blood pressure control with ACE inhibitors or ARBs targeting systolic BP <120 mmHg, dietary sodium restriction to <2.0 g/day, and proteinuria reduction as the primary treatment goals. 1, 2

Initial Diagnostic Approach

• Obtain kidney biopsy as the gold standard for diagnosis to guide specific treatment selection, as the type of glomerulonephritis determines therapy intensity and duration 1, 2
• Assess proteinuria using 24-hour urine collection in adults or first morning protein-creatinine ratio in children 2
• Evaluate eGFR using CKD-EPI equation in adults and modified Schwartz equation in children 2
• Examine urine sediment for erythrocyte morphology, red cell casts, and acanthocytes 2

Supportive Care Framework (First-Line for All Patients)

Blood Pressure Management

• Initiate ACE inhibitors or ARBs at maximally tolerated doses as first-line therapy for all patients with hypertension and proteinuria 1, 2, 3
• Target systolic BP <120 mmHg in adults using standardized office measurement 1, 4
• Target 24-hour mean arterial pressure at ≤50th percentile for age, sex, and height in children by ambulatory monitoring 1, 4
• Hold RAS inhibitors during intercurrent illnesses with volume depletion risk 1, 4
• Add calcium channel blockers and diuretics if BP target not achieved with RAS blockade alone 3

Edema and Volume Management

• Restrict dietary sodium to <2.0 g/day to reduce edema, control BP, and manage proteinuria 4, 2
• Use loop diuretics as first-line agents for edema 1, 4
• Add mechanistically different diuretics (thiazides or potassium-sparing agents) if insufficient response 1, 4
• Monitor for hyponatremia, hypokalemia, GFR reduction, and volume depletion 1, 4

Dietary Protein Management

• For nephrotic-range proteinuria: prescribe 0.8-1 g/kg/day with additional protein up to 5 g/day to compensate for urinary losses 1, 4
• For eGFR <60 ml/min/1.73 m² with nephrotic-range proteinuria: limit to 0.8 g/kg/day 1, 4
• Never restrict protein below 0.6 g/kg/day due to malnutrition risk 2
• Target caloric intake of 35 kcal/kg/day, or 30-35 kcal/kg/day if eGFR <60 ml/min/1.73 m² 2

Disease-Specific Immunosuppressive Therapy

Membranous Nephropathy

• Observe for 6 months before initiating immunosuppression unless severe symptoms or declining kidney function present 1, 4
• For patients requiring treatment: administer 6-month course of alternating monthly cycles of oral and IV corticosteroids with oral cyclophosphamide (preferred over chlorambucil) 1, 4
• Adjust cyclophosphamide doses according to patient age and eGFR 4
• Use cyclosporine or tacrolimus for at least 6 months in patients with contraindications to cyclophosphamide regimens 1, 4

Focal Segmental Glomerulosclerosis (FSGS)

• Administer high-dose corticosteroids for minimum 4 weeks, extending up to 16 weeks as tolerated 1, 4
• Taper corticosteroids slowly over 6 months after achieving complete remission 1, 4
• Switch to calcineurin inhibitors (cyclosporine or tacrolimus) for steroid-resistant or steroid-intolerant cases 1, 4

Membranoproliferative Glomerulonephritis (MPGN)

• Use oral cyclophosphamide or mycophenolate mofetil plus low-dose alternate-day or daily corticosteroids for nephrotic syndrome with progressive kidney function decline, limiting initial therapy to <6 months 1
• For children with MPGN and nephrotic syndrome and/or impaired renal function: trial alternate-day steroids (40 mg/m²) for 6-12 months 1
• Treat conservatively if normal eGFR and non-nephrotic-range proteinuria present 1
• Avoid immunosuppression in advanced CKD, severe tubulointerstitial fibrosis, or small kidney size 1

IgA Nephropathy

• Focus on optimized supportive care as primary management 2
• Provide lifestyle advice including dietary sodium restriction, smoking cessation, weight control, and exercise 2
• Assess and manage cardiovascular risk factors 2

Infection-Related Glomerulonephritis

• Treat post-streptococcal GN with penicillin (or erythromycin if penicillin-allergic) even without persistent infection 1
• Consider corticosteroids for severe crescentic post-streptococcal GN based on anecdotal evidence 1
• Continue antibiotics for 4-6 weeks in infective endocarditis-related GN 1

Immunosuppression Safety Protocol

Pre-Treatment Screening

• Screen for latent tuberculosis, hepatitis B, hepatitis C, HIV, and syphilis 4, 2
• Review and update vaccination status before starting immunosuppression 1, 4, 2
• Consider fertility preservation where indicated 1, 4, 2

Prophylaxis and Vaccination

• Administer pneumococcal vaccine to all patients with nephrotic syndrome 4
• Ensure influenza vaccine for patients and household contacts 4
• Provide herpes zoster vaccination (Shingrix) 1, 4
• Prescribe prophylactic trimethoprim-sulfamethoxazole for patients receiving high-dose prednisone or other immunosuppressive agents 1, 4

Ongoing Monitoring During Immunosuppression

• Monitor therapeutic drug levels where clinically indicated 1, 4, 2
• Surveil for development of cancers or infections 1, 4, 2

Monitoring and Treatment Response Assessment

• Assess proteinuria regularly as the primary marker of treatment response and surrogate endpoint 1, 2
• Monitor for ≥40% decline in eGFR from baseline over 2-3 years as surrogate outcome for kidney failure 1, 4, 2
• Perform repeat kidney biopsy only if rapidly deteriorating kidney function (doubling of serum creatinine over 1-2 months) or if it will alter diagnosis or therapeutic plan 1, 4, 2

Critical Pitfalls to Avoid

• Do not confuse IgA-dominant postinfectious GN with idiopathic IgA nephropathy or Henoch-Schönlein purpura, as this leads to inappropriate corticosteroid treatment 1
• Recognize that complete clinical remission may not be possible in all forms of chronic glomerulonephritis, and prolonged or multiple rounds of immunosuppression may be required 1, 2
• Avoid excessive protein restriction below 0.6 g/kg/day due to malnutrition risk 2
• Do not use protein restriction in children, as safety has not been established 1, 2
• Balance immunosuppression intensity against cumulative toxic drug exposure over time 1