What are the recommendations for preventing and managing influenza A in patients with post-infective glomerulonephritis, particularly those with underlying kidney disease?

Influenza A Prevention and Management in Post-Infectious Glomerulonephritis with Kidney Disease

All patients with post-infectious glomerulonephritis (PIGN) and underlying kidney disease should receive annual inactivated influenza vaccination, as these patients are at high risk for severe influenza complications and vaccination significantly reduces morbidity and mortality. 1

Vaccination Strategy

Primary Prevention

• Administer inactivated influenza vaccine annually to all patients with glomerular disease, chronic kidney disease (CKD), and nephrotic syndrome 1
• Vaccinate household contacts and close caregivers to create a protective barrier around vulnerable patients 1
• Only use inactivated influenza vaccines (standard quadrivalent or high-dose trivalent) in patients with kidney disease—live attenuated influenza vaccine (LAIV) is absolutely contraindicated in immunocompromised patients and those on dialysis 1

Timing Considerations

• Patients with glomerulonephritis on immunosuppression may have suboptimal vaccine responses, but vaccination remains beneficial for preventing severe complications, hospitalization, and death even when antibody responses are reduced 1
• For patients receiving immunosuppressive therapy, administer influenza vaccine before initiating treatment when possible, though vaccination should not be delayed if immunosuppression has already begun 1
• Update vaccination status and ensure influenza vaccination is current before starting any immunosuppressive regimen 1, 2

Treatment of Influenza A Infection

Antiviral Therapy

Initiate oseltamivir (75 mg twice daily for 5 days in adults with normal renal function) immediately upon symptom onset or strong clinical suspicion, without waiting for confirmatory testing. 3

Dosage Adjustments for Renal Impairment

• Moderate renal impairment (CrCl >30 to 60 mL/min): 30 mg twice daily for 5 days 3
• Severe renal impairment (CrCl >10 to 30 mL/min): 30 mg once daily for 5 days 3
• End-stage renal disease on hemodialysis: 30 mg immediately, then 30 mg after each hemodialysis cycle (not to exceed 5 days total) 3
• Continuous ambulatory peritoneal dialysis: Single 30 mg dose 3

Immunosuppression Management

• Consider reducing immunosuppression in patients with significant influenza illness to allow adequate immune response to the infection 1
• Balance the risk of glomerulonephritis progression against the risk of severe influenza complications when making immunosuppression adjustments 1

Monitoring for Complications

• Monitor for viral replication beyond 7-10 days despite antiviral therapy, which should raise concern for antiviral resistance 1
• Watch for progression of symptoms despite therapy, indicating potential treatment failure or resistant virus 1
• Consider IV zanamivir or peramivir for severe cases or suspected resistance, though these require special authorization 1

Post-Exposure Prophylaxis

Selective Use

• Routine chemoprophylaxis for the duration of influenza season is not recommended due to concerns about drug resistance 1
• Consider prophylaxis for select high-risk patients: recent transplant recipients, those recently receiving lymphocyte-depleting antibodies, and patients in whom vaccination is contraindicated 1

Post-Exposure Strategy

• Counsel patients with known influenza exposure to watch for early signs and symptoms 1
• Provide a prescription for treatment-dose antivirals to be initiated at the first sign of symptoms 1

Infection Control Measures

Patient and Family Education

• Strict hand hygiene using soap and water or alcohol-based hand gels, particularly after coughing or sneezing 1
• Practice respiratory etiquette: cover nose and mouth with tissue when coughing/sneezing, dispose of tissue immediately, or cough into sleeve if no tissue available 1
• Avoid contact with individuals diagnosed with influenza 1
• Limit non-essential visits to healthcare facilities during epidemic periods 1

Special Considerations and Caveats

Vaccine Safety

• While rare cases of glomerulonephritis following influenza vaccination have been reported (membranous nephropathy, IgA-dominant nephritis, pauci-immune crescentic glomerulonephritis), these are extremely uncommon 4, 5
• The established benefits of preventing severe influenza far outweigh the minimal risk of vaccine-associated glomerular complications 1
• The estimated risk of Guillain-Barré syndrome (approximately 1 per million vaccinated) is substantially less than the risk of severe influenza complications 1

Contraindications to Vaccination

• Severe allergic reaction (anaphylaxis) to any vaccine component or previous influenza vaccine dose 1
• History of Guillain-Barré syndrome within 6 weeks of previous influenza vaccination (relative contraindication—weigh risks vs. benefits) 1

Supportive Care During Acute Illness

• Maintain sodium restriction <2.0 g/day to manage fluid overload and hypertension 1, 6, 2
• Use diuretics and antihypertensive medications (preferably ACE inhibitors or ARBs) to control blood pressure and edema 6, 2
• Monitor kidney function closely with serial creatinine and eGFR measurements 6, 2
• Provide renal replacement therapy if severe acute kidney injury develops 6, 7

Common Pitfalls to Avoid

• Do not delay antiviral treatment while awaiting laboratory confirmation of influenza—clinical suspicion is sufficient to initiate therapy 1
• Do not use live attenuated influenza vaccine in any patient with kidney disease, immunosuppression, or nephrotic syndrome 1
• Do not withhold vaccination due to concerns about triggering glomerulonephritis—the risk is negligible compared to influenza complications 1, 4, 5
• Remember to adjust oseltamivir dosing for renal function to avoid toxicity while maintaining efficacy 3