What is the initial treatment for glomerulonephritis?

Initial Treatment of Glomerulonephritis

The initial treatment of glomerulonephritis depends entirely on the specific type diagnosed by kidney biopsy, but for most primary glomerular diseases presenting with nephrotic syndrome, corticosteroids form the cornerstone of initial therapy, while post-infectious glomerulonephritis requires only antibiotics and supportive care without immunosuppression. 1, 2

Treatment Algorithm by Glomerulonephritis Type

Post-Infectious Glomerulonephritis

• Administer antibiotics immediately (penicillin or erythromycin for streptococcal infections, even if active infection has resolved) to reduce antigenic load 2
• Provide supportive management only: restrict sodium to <2.0 g/day, use diuretics for fluid overload, target blood pressure <130/80 mmHg 2
• Do NOT use corticosteroids except in rare cases of severe crescentic disease with rapidly progressive renal failure 2
• Critical caveat: Never use corticosteroids for IgA-dominant post-infectious glomerulonephritis (typically staphylococcal, especially in elderly/diabetic patients) 2

Minimal Change Disease (MCD)

• Start prednisone 1 mg/kg/day (maximum 80 mg) or alternate-day 2 mg/kg (maximum 120 mg) as first-line therapy 1
• Continue high-dose corticosteroids for minimum 4 weeks if complete remission achieved, maximum 16 weeks if remission not achieved 1
• Taper slowly over 6 months after achieving complete remission 1
• Alternative for steroid contraindications: Use calcineurin inhibitors (cyclosporine 3-5 mg/kg/day or tacrolimus 0.05-0.1 mg/kg/day) in patients with uncontrolled diabetes, psychiatric conditions, or severe osteoporosis 1

Focal Segmental Glomerulosclerosis (FSGS)

• Rule out secondary causes first (obesity, reduced nephron mass, medications) before starting immunosuppression 1
• For idiopathic FSGS with nephrotic syndrome: Start prednisone 1 mg/kg/day (maximum 80 mg) or alternate-day 2 mg/kg (maximum 120 mg) 1
• Maintain high-dose corticosteroids for minimum 4 weeks, maximum 16 weeks as tolerated or until complete remission 1
• Consider calcineurin inhibitors as first-line in patients with obesity, strong family history of diabetes, or elevated HbA1c (cyclosporine preferred over tacrolimus to avoid precipitating diabetes) 1
• Always add ACE inhibitor or ARB for renin-angiotensin-aldosterone system blockade regardless of immunosuppression choice 1

Membranous Nephropathy (IMN)

• Do NOT use corticosteroid monotherapy for initial treatment 1
• For high-risk patients (nephrotic syndrome with progressive decline in kidney function): Use cyclical regimen alternating corticosteroids with alkylating agents (cyclophosphamide or chlorambucil) over 6 months 1
• Alternative first-line: Calcineurin inhibitors (cyclosporine or tacrolimus) for minimum 6 months, continued for at least 12 months if partial remission achieved 1
• Do NOT use mycophenolate mofetil monotherapy for initial treatment 1
• Add prophylactic anticoagulation if serum albumin <2.5 g/dl with additional thrombosis risk factors 1

Membranoproliferative Glomerulonephritis (MPGN)

• Evaluate for underlying diseases first (hepatitis C, hepatitis B, cryoglobulinemia, monoclonal gammopathy) before treating as idiopathic 1
• For presumed idiopathic MPGN with nephrotic syndrome and progressive kidney function decline: Use oral cyclophosphamide OR mycophenolate mofetil PLUS low-dose alternate-day or daily corticosteroids for less than 6 months 1

Lupus Nephritis (Class IV)

• Start corticosteroids combined with either cyclophosphamide OR mycophenolate mofetil as initial therapy 1
• Switch therapy within 3 months if worsening occurs (rising creatinine, worsening proteinuria) or perform repeat kidney biopsy 1

Universal Supportive Measures (All Types)

• Blood pressure control: Target <130/80 mmHg (or <125/75 mmHg if proteinuria >1 g/day) 2
• ACE inhibitor or ARB: Use in all patients with significant proteinuria 1
• Statin therapy: Control cholesterol in nephrotic syndrome 1
• Sodium restriction: <2.0 g/day for fluid retention and hypertension 2
• Diuretics: First-line for managing fluid overload 2

Critical Pitfalls to Avoid

• Never start immunosuppression without kidney biopsy confirmation of the specific glomerulonephritis type—treatment varies dramatically by diagnosis 1
• Do not use corticosteroids alone for membranous nephropathy—this is ineffective and increases toxicity risk 1
• Avoid immunosuppression in secondary FSGS—these patients need cardiovascular risk reduction, not steroids 1
• Monitor for steroid-induced diabetes closely, especially in obese patients and those with family history—consider calcineurin inhibitors instead 1
• Do not delay treatment in rapidly progressive glomerulonephritis—these patients may require urgent plasmapheresis and high-dose immunosuppression 1