What is the treatment for acute glomerulonephritis?

Treatment of Acute Glomerulonephritis

The treatment of acute glomerulonephritis is primarily supportive care with diuretics, sodium restriction, and blood pressure control using ACE inhibitors or ARBs, while reserving immunosuppressive therapy only for specific severe or progressive cases. 1, 2

Initial Management Approach

The cornerstone of acute glomerulonephritis management is addressing the underlying cause while providing supportive care for kidney manifestations. 1 Treatment intensity depends on the specific type of glomerulonephritis, disease severity, and presenting symptoms. 1

Immediate Supportive Care

Blood Pressure Control:

• Use ACE inhibitors or ARBs at maximally tolerated doses as first-line therapy for patients with both hypertension and proteinuria. 1, 2
• Target systolic blood pressure <120 mmHg in adults using standardized office measurement. 1, 2
• In children, target 24-hour mean arterial pressure at ≤50th percentile for age, sex, and height by ambulatory monitoring. 1, 2
• Hold RAS inhibitors during intercurrent illnesses with volume depletion risk. 1, 2

Edema Management:

• Restrict dietary sodium to <2.0 g/day to reduce edema, control blood pressure, and manage proteinuria. 2, 3
• Use diuretics as first-line agents for edema management. 1, 2
• Add mechanistically different diuretics if response is insufficient. 1, 2
• Monitor for hyponatremia, hypokalemia, GFR reduction, and volume depletion. 1, 2

Dietary Management:

• For nephrotic-range proteinuria: 0.8-1 g/kg/day protein with additional protein to compensate for losses (up to 5 g/day). 1, 2
• For eGFR <60 ml/min/1.73 m² with nephrotic-range proteinuria: limit to 0.8 g/kg/day. 1, 2
• Never restrict protein below 0.6 g/kg/day due to malnutrition risk. 3

Disease-Specific Treatment Algorithms

Post-Streptococcal Glomerulonephritis

For typical post-streptococcal GN, treat with penicillin (or erythromycin if penicillin-allergic) even in absence of persistent infection. 1, 4

• Manage nephritic syndrome with diuretics, antihypertensives, supportive care, and dialysis if necessary. 1
• For severe crescentic post-streptococcal GN with rapidly progressive disease, consider corticosteroids based on anecdotal evidence. 1
• Most patients recover fully with supportive care alone. 4

Infection-Related Glomerulonephritis (Non-Streptococcal)

For infective endocarditis-related GN, continue antibiotic treatment for 4-6 weeks. 1

• Recognize that hematuria, proteinuria, and azotemia may not resolve for months despite appropriate antibiotic therapy. 1
• For shunt nephritis, treat the infectious disease with standard approaches to kidney manifestations. 5

Viral-Associated Glomerulonephritis

HCV-infected patients with CKD stages 1 or 2 and GN:

• Use combined antiviral treatment with pegylated interferon and ribavirin. 5, 1

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

HCV with mixed cryoglobulinemia (IgG/IgM) with nephrotic proteinuria or progressive disease:

• Use plasmapheresis, rituximab, or cyclophosphamide in conjunction with IV methylprednisolone and concomitant antiviral therapy. 5

HBV infection and GN:

• Treat with interferon-α or nucleoside analogues as recommended for the general population. 5, 1
• Adjust dosing to degree of kidney function. 5

HIV-associated nephropathy:

• Initiate antiretroviral therapy in all patients with biopsy-proven HIV-associated nephropathy, regardless of CD4 count. 5

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. 5, 1

• Evaluate patients for underlying diseases before considering specific treatment. 5
• Patients with normal eGFR and non-nephrotic-range proteinuria may be treated conservatively. 1
• Avoid immunosuppression in advanced CKD, severe tubulointerstitial fibrosis, small kidney size, or chronic inactive disease. 1

Membranous Nephropathy

Consider observation for 6 months before initiating immunosuppressive therapy unless there are severe symptoms or declining kidney function. 1, 2

• 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, 2
• Consider cyclosporine or tacrolimus for at least 6 months in patients with contraindications to cyclical corticosteroid/alkylating-agent regimens. 1, 2
• Do not use corticosteroid monotherapy for initial therapy. 5

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, 2

• Taper corticosteroids slowly over 6 months after achieving complete remission. 1, 2
• For steroid-resistant or steroid-intolerant cases, use calcineurin inhibitors (cyclosporine or tacrolimus). 1, 2

Immunosuppression Safety Protocol

Before initiating immunosuppression:

• Screen for latent infections including tuberculosis, hepatitis B, hepatitis C, HIV, and syphilis. 2, 3
• Review vaccination status and update as required. 1, 2, 3
• Consider fertility preservation where indicated. 1, 2, 3

During immunosuppressive therapy:

• Provide pneumococcal vaccine, influenza vaccine, and herpes zoster vaccination (Shingrix). 1, 2
• Consider prophylactic trimethoprim-sulfamethoxazole for patients receiving high-dose prednisone or other immunosuppressive agents. 1, 2
• Monitor therapeutic drug levels where clinically indicated. 1, 2, 3
• Monitor for development of cancers or infections. 1, 2, 3

Monitoring and Follow-up

Assess proteinuria regularly as 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, 2, 3
• Perform repeat kidney biopsy only if the patient has rapidly deteriorating kidney function (doubling of serum creatinine over 1-2 months) or if it will potentially alter the diagnosis or therapeutic plan. 1, 2, 3

Critical Pitfalls to Avoid

IgA-dominant postinfectious GN must be distinguished from idiopathic IgA nephropathy and Henoch-Schönlein purpura to avoid inappropriate corticosteroid treatment. 1

• Prolonged or multiple rounds of immunosuppression increase toxic drug exposure over time. 1, 3
• Do not use corticosteroids or immunosuppressive agents for schistosomal-associated GN, as the GN results from infection and immune response to the organism. 5
• For parasitic infections (malarial, schistosomal, or filarial), treat with appropriate antiparasitic agents in sufficient dosage and duration to eradicate the organism. 5