What is the recommended dose of prednisone (corticosteroid) for poststreptococcal glomerulonephritis (PSGN)?

Prednisone Dosing for Poststreptococcal Glomerulonephritis

Direct Answer

Corticosteroids are NOT routinely recommended for poststreptococcal glomerulonephritis (PSGN) and should only be considered for severe crescentic disease based on anecdotal evidence alone. 1

Standard Management Approach

The cornerstone of PSGN treatment is supportive care, not immunosuppression:

• Treat the underlying infection with penicillin (or erythromycin if penicillin-allergic) even in the absence of persistent infection to decrease antigenic load 1
• Manage nephritic syndrome with diuretics, antihypertensives, and dialysis if necessary 1
• ACE inhibitors (captopril, enalapril) provide superior blood pressure control and improvement in echocardiographic changes compared to other antihypertensives 2
• Nifedipine is effective for acute hypertension control 2

When Corticosteroids May Be Considered

Severe crescentic PSGN is the only indication where corticosteroids might be used, though the evidence is weak:

• This recommendation is based on anecdotal evidence only 1
• One case report showed improvement with corticosteroids in an adult with crescentic PSGN and nephrotic syndrome 3
• However, a controlled trial in children with crescentic PSGN (>60% of glomeruli with crescents) found no advantage of quintuple therapy (including prednisone, azathioprine, cyclophosphamide) over supportive care alone 4
• A systematic review concluded that evidence-based treatment limitations prevent any therapeutic recommendation for immunosuppression in APSGN 2

Critical Contraindications

Do NOT use corticosteroids in these situations:

• IgA-dominant postinfectious glomerulonephritis must be distinguished from classic PSGN, as it should not be treated with corticosteroids 1
• This variant typically occurs with staphylococcal infections (including MRSA), is common in elderly and diabetic patients, and has poor renal outcomes 1
• Hypocomplementemia is present in the majority of IgA-dominant cases 1

Prognosis Without Immunosuppression

The natural history of PSGN is generally excellent without corticosteroids:

• The majority of children with epidemic PSGN have excellent prognosis with supportive care alone 2
• In adults followed for 1-14 years (mean 7 years), the majority had good outcomes with supportive care 5
• Nine of ten children with severe crescentic PSGN maintained normal creatinine clearance for 8-60 months with supportive care alone 4
• Histological resolution may take up to 9 years but occurs without immunosuppression 5

Clinical Algorithm

For typical PSGN:

1. Confirm diagnosis (history of streptococcal infection, elevated ASO titer, low complement) 1
2. Initiate penicillin therapy 1
3. Provide supportive care (diuretics, ACE inhibitors for hypertension) 1, 2
4. Monitor for resolution over weeks to months 1

For crescentic PSGN with rapidly progressive renal failure:

1. Confirm diagnosis with renal biopsy showing crescents 4, 3
2. Exclude IgA-dominant variant (check for IgA dominance on immunofluorescence) 1
3. Consider corticosteroids only after careful risk-benefit discussion with patient 1, 3
4. No established dosing regimen exists; case reports used variable regimens 3

Key Pitfall to Avoid

The most critical error is treating IgA-dominant postinfectious glomerulonephritis with corticosteroids, mistaking it for classic PSGN or IgA nephropathy. This variant requires only supportive care and treatment of the underlying infection (often staphylococcal). 1