Glomerulonephritis is inflammation of the glomeruli, which are structures in your kidneys that are made up of tiny blood vessels. Glomerular diseases are an important cause of end stage renal disease. Kidney biopsy is mandatory for diagnosis. Treatment with early diagnosis may stopped or prevent end-stage renal failure. Treatment of glomerulonephritis is regulated by the underlying glomerulonephritis type. Glomerulonephritis treatment options include blood pressure control, protein restriction, immunosuppression, and plasmapheresis. In this article we tried to discuss primer glomerulonephritis (minimal change disease, focal segmental glomerulosclerosis, idiopathic membranous glomerulonephritis, IgA nephropathy, idiopathic membranoproliferative glomerulonephritis, C3 glomerulopathy, pauci immune glomerulonephritis, and antiglomerular basal membrane disease) treatments in the context of literature.

• Glomerulonephritis
• Treatment
• Proteinüria

Huzmeli C, Candan F (2017) Overview of Glomerulonephritis Treatment. J Autoimmun Res 4(3): 1026.

As Kidney Disease Improving Global Outcomes (KDIGO) supportive treatment, the treatment of hyperlipidaemia with statins and proteinuria treatment with angiotensin-converting enzyme inhibitör (ACEI) / angiotensin receptor blocker (ARB) in normotensives is not recommended in the first episode. The use of ACEI / ARB can be considered in non-quick remission, frequently recurrent and steroid-dependent patients. Diuretic addition with ACEI or ARB may provide the basis for acute kidney damage [1,2].

According to KDIGO guidelines, corticosteroids (prednisolone 1mg / kg maximum 80mg or 2mg / kg maximum 120mg daily) are recommended as initial treatment for patients with nephrotic syndrome. Corticosteroids are recommended for a minimum of 4 weeks if full remission is provided and a maximum of 16 weeks if complete remission is not provided. Steroid therapy is recommended not to exceed 24 months. Cyclophosphamide or calcineurin inhibitors with frequent relapse and steroid dependence, intolerance or contraindication to corticosteroids, are recommended. If prednisolone, cyclophosphamide, cyclosporine and tacrolimus intolerance are present, mycophenolate mofetil (MMF) may be given [1,3,4]. MMF use has been reported to be effective (about 60%–70% of patients) only in small patient cohorts [5,6]. It has been shown that rituximab is effective in the treatment of patients who are frequently relapsed or steroid-dependent [7,8].

In all Focal Segmental Glomerulosclerosis (FSGS) patients with subnephrotic proteinuria, immunosuppressive therapy is not recommended. ACEI / ARB and sodium restriction are recommended in all FSGS patients. It is thought that immunosuppressives are not injured in cases with intense glomerulosclerosis and interstitial fibrosis. If there is nephrotic syndrome clinic, corticosteroids (prednisolone daily 1mg / kg maximum 80mg or 2mg / kg daily excess maximum 120mg) and immunosuppressive therapy are recommended. If there is intolerance or contraindication to corticosteroids, alternatively calcineurin inhibitors are recommended. However, for calcineurin use, it is necessary not to have significant renal dysfunction at baseline. The combination of high doses of dexamethasone and MMF is recommended for patients who cannot tolerate cyclosporine. The use of steroids in combination with calcineurin therapy increases complete and partial remission of proteinuria in the treatment of steroid-resistant FSGS. Cyclosporine was effective in treatment but relapse rates were high after drug withdrawal [1,9,10]. Corticosteroids are used in combination with MMF and has been shown to be effective [11,12]. Several case reports have shown that rituximab is successfully used in adult patients with steroid-dependent but non-steroid-resistant FSGS [13-15].

KDIGO suggests immunosuppressive treatment in the presence of nephrotic syndrome and any of these. Despite the use of antihypertensive and antiproteinuric treatment for at least 6 months, the proteinuria is always ≥ 4 gr / day, provided severe life-threatening symptoms associated with nephrotic syndrome and glomerular filtration rate (GFR) is not less than 25-30mL / min, it is defined as > 30% increase in serum creatinine in 6-12 months period. Membranous Glomerulonephritis (MNG) spontaneous remission is seen in one-third of the patients. If the patient has serum creatinine> 3.5 mg / dL or GFR <30 mL / min, in patients with reduced renal size by ultrasonography (<8 cm) or in life-threatening serious infections, immunosuppressive therapy is not recommended. KDIGO recommends monthly steroid and oral cyclophosphamide in initial treatment [1].

If the amount of proteinuria of MGN is ≤ 4 gr/day and renal functions are normal, blood pressure ≤ 125 / 75mmHg, ACEI / ARB, diet, follow-up is recommended and immunosuppressive treatment is not recommended. If the amount of proteinuria is ≥ 4 gr/day and <8 gr/kg and renal functions are normal, blood pressure ≤ 125 / 75mmHg ACEI / ARB, diet, 6/12 months followup is recommended. If these patients persistent proteinuria ≥ 4 gr/day in follow-up, corticosteroid + cytotoxic agent or calcineurin inhibitors or rituximab are recommended to patients. If proteinuria is present on ≥ 8 gr/day and/or if renal function is impaired, blood pressure ≤ 125 / 75mmHg ACEI / ARB and diet follow-up are recommended. For persistent proteinuria, ≥ 8gr / day corticosteroid +cytotoxic agent or rituximab or calcineurin inhibitors are recommended. KDIGO recommend that initial therapy consist of a 6-month course of alternating monthly cycles of oral and intravenos corticosteroids (intravenous methylprednisolone 1 gr daily for three doses, then oral methyprednisolone 0.5 mg/kg/d for 27 days), and oral alkylating agents (cyclophosphamide 2 mg / kg / day). It is recommended not to use corticosteroid and MMF monotherapy. In nephrotic syndrome relapses, a remission-induced regimen is recommended. However, if alternate steroid and alkalizing agents are given, the same regimen is recommended only once more. It is recommended that treatment agents be changed in conditions where initial therapy is resistant [1,16-23]. Plasma exchange, intravenous immunoglobulin (IVIG) and rituximab treatment have been shown to be successful in treatment resistant patients [24].

Current guidelines suggest that patients who have persistent proteinuria ≥ 1 g/day despite a trial of the renin angiotensin aldosterone system blockade of adequate duration and good blood pressure control should be considered candidates for immunosuppressive therapy. KDIGO GFR> 50ml / min and 3-6 months conservative treatment (Supply of active blood pressure with ACEI / ARB) persistent proteinuria ≥ 1gr / day disease 6 months corticosteroid treatment is recommended. If there is no rapid renal function and no crescentic glomerulonephritis, immunosuppressive therapy with GFR <30 ml /min is not recommended. If there is rapidly worsening renal function in KDIGO IgA nephropathy, and if crescentic glomerulonephritis, corticosteroids and cyclophosphamide are recommended. KDIGO does not recommend using MMF [1,25-28]. In the studies conducted, there was no difference between MMF and other immunosuppressive agents in the treatment of IgA nephropathy [29,30]. It was emphasized that despite the treatment with optimal blood pressure control for KDIGO 6 months, persistent proteinuria patients could be given fish oil. It also does not recommend the use of anti-agregan drugs [1].

In patients with non-nephrotic proteinuria and normal or stable kidney function, ACEI or ARB proteinuria and hypertension control are recommended. Immunosuppressive therapy is recommended for patients with nephrotic proteinuria or if there is no renal dysfunction. Albumin infusion is recommended when diuretic, fluid and salt restriction, protein intake of 0.8-1 gr/kg/day protein and high carbohydrate intake are required in oedema treatment. In adults, steroid monotherapy has not been shown to be beneficial in the treatment. Cyclophosphamide or mycophenolate combined with steroids is recommended for these patients. If patients have rapidly progressive renal insufficiency, oral cyclophosphamide or MMF is recommended as a plus steroid followed by oral steroids. Combined dipyridamole and aspirin should be evaluated in the treatment. Also, quite interestingly the benefit of anticoagulant therapy has not been shown. In a previous study conducted, it was shown that combined treatment reduced GFR significantly compared to the control group. Rituximab has been shown to be effective in a small number of cases in studies using it [31-35].

C3 glomerulopathy (C3G) treatment is in the form of nonspecific treatment, immunosuppressive treatments, plasma treatment, and inhibition of complement activation. Nonspecific treatment, blood pressure control (priority agents include ACEI/ ARB), reduction of proteinuria and reduction of serum lipid level has beneficial effects on the progression of C3G. Optimal blood pressure control 500mg/day despite the supportive treatment, if the renal biopsy finds moderate inflammatory findings or if the renal function is impaired prednisolone or MMF is recommended.

Proteinuria> 2 gr/day for supportive treatment of severe disease, prednisolone and immunosuppressive treatment, increased serum creatinine suggesting risk for progressive disease at onset, if there are signs of severe inflammation during renal biopsy, prednisolone pulse dosing, as well as other anti-cellular immunosuppressive,have had limited success in rapidly progressive disease. Data are insufficient to recommend eculizumab as a first-line agent for the treatment of rapidly [36,37].

As KDIGO initial treatment, cyclophosphamide with corticosteroid therapy is recommended. If cyclophosphamide is contraindicated, rituximab is recommended instead. For patients who require dialysis treatment or have rapid serum creatinine increase, plasmapheresis is recommended. Azathioprine is recommended in maintenance treatment, MMF is recommended there are allergies. If you have intolerance to both drugs, then methotrexate recommended. The addition of rituximab to sites of glucocorticoid and cyclophosphamide resistant to induction therapy and IVIG or plasmapheresis is also recommended. If upper respiratory tract disease is present, trimethoprim sulfamethoxazole is recommended [1].

European Vasculitis Society/European League against Rheumatism (EUVAS/EULAR) Group suggests cyclophosphamide or rituximab in addition to corticosteroids in induction therapy. Mesna can be given either orally or intravenously to prevent bladder toxicity. Methotrexate and MMF may only be used in induction therapy in the absence of an organ or life-threatening conditions. Serum creatinine value is> 500 μmol / L (6.5 mg / dL), the vital organ and life-threatening conditions are suggested to cause disease plasma exchange. Azathioprine or methotrexate is recommended in maintenance treatment. If there is intolerance against them, Leflunomide is recommended. It suggests the use of prophylactic trimethoprim sulfamethoxazole [38-43].

In KDIGO initial treatment, glucocorticoid and cyclophosphamide are recommended. Plasmapheresis is recommended in addition to patients with dialysis-dependent and pulmonary haemorrhage, who have the crescent of adequate renal biopsy. In the case of anti glomerular basal membrane disease, maintenance treatment is not recommended. As prophylaxis, co-trimoxazole antifungal (nystatin) proton pump inhibitors, or h2 antogonis, calcium and vitamin D are recommended. For immunoadsorption autoimmune diseases, it is an alternative treatment for circulating autoantibodies. This treatment is used for anti-glomerular basal membrane disease [1,44-47].

1. Daniel CC, John F, Terence CH, Zhi HL, Fernando CF, Sergio AM, et al. Kidney Disease Improving Global Outcomes Glomerulonephritis Work Group: KDIGO clinical practice guideline for glomerulonephritis. Kidney Int. 2012; 2:139-274.

2. Yalavarthy R, Smith ML, Edelstein C. Acute kidney injury complicating minimal change disease: the case for careful use of diuretics and angiotensin-converting enzyme inhibitors. Nephrology (Carlton). 2007; 12: 529-531.

3. Palmer SC, Nand K, Strippoli GF. Interventions for minimal change disease in adults with nephrotic syndrome. Cochrane Database Syst Rev. 2008; CD001537.

4. Canetta PA, Radhakrishnan J. The evidence-based approach to adult-onset idiopathic nephrotic syndrome. Front Pediatr. 2015; 3: 78.

5. Pesavento TE, Bay WH, Agarwal G, Hernandez RA Jr, Hebert LA. Mycophenolate therapy in frequently relapsing minimal change disease that has failed cyclophosphamide therapy. Am J Kidney Dis. 2004; 43: e3-e6.

6. Siu YP, Tong MK, Leung K, Kwan TH , Au TC. The use of entericcoated mycophenolate sodium in the treatment of relapsing and steroid- dependent minimal change disease. J Nephrol. 2008; 21: 127-131.

7. Munyentwali H, Bouachi K, Audard V, Remy P, Lang P, Mojaat R, et al. Rituximab is an efficient and safe treatment in adults with steroid-dependent minimal change disease. Kidney Int. 2013; 83: 511-516.

8. Guitard J, Hebral AL, Fakhouri F, Medin C, Snaedal-Jonsdottir S, Korkeila M. Rituximab for minimal-change nephrotic syndrome in adulthood: predictive factors for response, long-term outcomes and tolerance. Nephrol Dial Transpl. 2014; 29: 2084-2091.

9. Cattran DC, Appel GB. Treatment of primary focal segmental glomerulosclerosis. 2017.

10. Laurin LP, Nachman PH, Foster BJ. Calcineurin Inhibitors in the Treatment of Primary Focal Segmental Glomerulosclerosis: A Systematic Review and Meta-analysis of the Literature. Can J Kidney Health Dis. 2017.

11. Senthil NL, Ganguli A, Rathi M, Kohli HS, Gupta KL, Joshi K, et al. Mycophenolatemofetil or standard therapy for membranous nephropathy and focal segmental glomerulosclerosis: a pilot study. Nephrol Dial Transplant. 2008; 23: 1926-1930.

12. Choi MJ, Eustace JA, Gimenez LF, Atta MG, Scheel PJ, Sothinathan R, et al. Mycophenolate mofetil treatment for primary glomerular diseases. Kidney Int. 2002; 61:1098.

13. Kronbichler A, König P, Busch M, Wolf G, Mayer G, Rudnicki M.. Rituximab in adult patients with multi-relapsing/steroid-dependent minimal change disease and focal segmental glomerulosclerosis: a report of 5 cases. Wien Klin Wochenschr. 2013; 125: 328.

14. Ochi A, Takei T, Nakayama K, Iwasaki C, Kamei D, Tsuruta Y, et al. Rituximab treatment for adult patients with focal segmental glomerulosclerosis. Intern Med. 2012; 51: 759.

15. Fernandez-Fresnedo G, Segarra A, González E, Alexandru S, Delgado R, Ramos N, et al. Rituximab treatment of adult patients with steroidresistant focal segmental glomerulosclerosis. Clin J Am Soc Nephrol. 2009; 4: 1317.

16. Troyanov S, Wall CA, Miller JA, Scholey JW, Cattran DC. Idiopathic membranous nephropathy: definition and relevance of a partial remission. Kidney Int. 2004; 66: 1199-1205.

17. Schieppati A, Mosconi L, Perna A, Mecca G, Bertani T, Garattini S, et al. Prognosis of untreated patients with idiopathic membranous nephropathy. N Engl J Med. 1993; 329: 85-89.

18. Polanco N, Gutie´rrez E, Covars? A, Ariza F, Carreño A, Vigil A, et al. Spontaneous remission of nephrotic syndrome in idiopathic membranous nephropathy. J Am Soc Nephrol. 2010; 21: 697-704.

19. Beck LH, Bonegio RGB, Lambeau G, Beck DM, Powell DW, Cummins TD, et al. M-type phospholipase A2 receptor as target antigen in idiopathic membranous nephropathy. N Engl J Med. 2009; 361: 11-21.

20. 20. Stanescu HC, Arcos-Burgos M, Medlar A, Bockenhauer D, Kottgen A, Dragomirescu L, et al. Risk HLA-DQA1 and PLA 2 R1 alleles in idiopathic membranous nephropathy. N Engl J Med. 2011; 364: 616- 626.

21. Van Den Brand JAJG, Van Dijk PR, Hofstra JM. Long-term outcomes in idiopathic membranous nephropathy using a restrictive treatment strategy. J Am Soc Nephrol. 2014; 25: 150-158.

22. Hoxha E, Harendza S, Pinnschmidt HO, Tomas NH, Helmchen U, Panzer U, et al. Spontaneous remission of proteinuria is a frequent event in phospholipase A 2 receptor antibody negative patients with membranous nephropathy. Nephrol Dial Transplant. 2015; 30: 1-8.

23. Jha V, Ganguli A, Saha TK, Kohli HS, Sud K, Gupta KL, et al. A randomized, controlled trial of steroids and cyclophosphamide in adults with nephrotic syndrome caused by idiopathic membranous nephropathy. J Am Soc Nephrol. 2007; 18: 1899-1904.

24. Müller-Deile J, Schiffer L, Hiss M, Haller H, Schiffer M. A new rescue regimen with plasma exchange and rituximab in highrisk membranous glomerulonephritis. Eur J Clin Invest. 2015; 45: 1260-1269.

25. Gharavi AG, Kiryluk K, Choi M, Li Y, Hou P, Xie J, et al. Genome wide association study identifies susceptibility loci for IgA nephropathy. Nat Genet. 2011; 43: 321-327.

26. Pozzi C, Bolasco PG, Fogazzi GB, Andrulli S, Altieri P, Ponticelli C, et al. Corticosteroids in IgA nephropathy: A randomised controlled trial. Lancet. 1999; 353: 883-887.

27. Pozzi C, Andrulli S, Del Vecchio L. Corticosteroid effectiveness in IgA nephropathy: Long-term results of a randomized, controlled trial. J Am Soc Nephrol. 2004; 15: 157-163.

28. Manno C, Torres DD, Rossini M, Melis P, Fogazzi GB, Altieri P, et al. Randomized controlled clinical trial of corticosteroids plus ACE-inhibitors with long-term follow-up in proteinuric IgA nephropathy. Nephrol Dial Transplant. 2009; 24: 3694-3701.

29. Hou JH, Le WB, Chen N, Wang WM, Liu ZS, Liu D, et al. Mycophenolate Mofetil Combined With Prednisone Versus Full-Dose Prednisone in IgA Nephropathy With Active Proliferative Lesions: A Randomized Controlled Trial Am J Kidney Dis. 2017; 15

30. Chen Y, Li Y, Yang S, Li Y, Liang M. Efficacy and safety of mycophenolate mofetil treatment in IgA nephropathy: a systematic review. BMC Nephrol. 2014; 5: 193.

31. D’Amicoand G, Ferrario F. “Mesangiocapillary glomerulonephritis,” J Am Soc Nephrol. 1992; S159-S166.

32. Patel T, Canetta P. Membranoproliferative glomerulonephritis. Updates. 2017; 02: 52.

33. Cattran DC, Cardella CJ, Roscoe JM, Charron RC, Rance PC, Ritchie SM, et al. Results of a controlled drug trial in membranoproliferative glomerulonephritis. Kidney Int. 1985; 27: 436.

34. Kong WY, Swaminathan R, Irish A. Our experience with rituximab therapy for adult-onset primary glomerulonephritis and review of literature. Int Urol Nephrol. 2013; 45: 795-802.

35. Dillon JJ, Hladunewich M, Haley WE, Reich HN, Cattran DC, Fervenza FC. Rituximab therapy for Type I membranoproliferative glomerulonephritis. Clin Nephrol. 2012; 77: 290-295.

36. Sethi S, Fervenza FC, Zhang Y, Zand L, Vrana JA, Nasr SH, et al. C3 glomerulonephritis: clinicopathological findings, complement abnormalities, glomerular proteomic profile, treatment, and follow-up. Kidney Int. 2012; 82: 465-473.

37. Goodship TH, Cook HT, Fakhouri F, Fernando CF, Ve´ronique FB, David K, et al. Atypical hemolytic uremic syndrome and C3 glomerulopathy: conclusions from a “Kidney Disease: Improving Global Outcomes” (KDIGO) Controversies Conference Kidney Int. 2017; 91: 539-551.

38. Sznajd J, Mukhtyar C. How to treat ANCA-associated vasculitis:practical messages from 2016 EULAR/ERA?EDTA recommendations. Pol Arch Med Wewn. 2016; 126: 781-788.

39. Ntatsaki E, Carruthers D, Chakravarty K, D’Cruz D, Harper L, Jayne D, et al. BSR and BHPR guideline for the management of adults with ANCA-associated vasculitis. Rheumatology. 2014 ; 53 : 2306 -230 9.

40. De Groot K, Rasmussen N, Bacon PA. Randomized trial of cyclophosphamide versus methotrexate for induction of remission in early systemic antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheum. 2005; 52: 246 -249.

41. Pagnoux C, Mahr A, Hamidou MA, Boffa JJ, Ruivard M, Ducroix JP, et al. Azathioprine or methotrexate maintenance for ANCA-associated vasculitis. N Engl J Med. 2008; 359: 2790-2803.

42. Jayne D, Rasmussen N, Andrassy K, Bacon P, Tervaert JW, Dadoniené J, et al. A randomized trial of maintenance therapy for vasculitis associated with antineutrophil cytoplasmic autoantibodies. N Engl J Med. 2003; 349: 36-44.

43. Hiemstra TF, Walsh M, Mahr A, Savage CO, de Groot K, Harper L, et al. Mycophenolate mofetil as azathioprine for remission maintenance in antineutrophil cytoplasmic antibody-associated vasculitis: a randomized controlled trial. JAMA. 2010; 304: 2381-2388.

44. Levy JB, Turner AN, Rees AJ, Pusey CD. Long-term outcome of antiglomerular basement membrane antibody disease treated with plasma Exchange and immunosuppression. Ann Intern Med. 2001; 134: 1033-1042.

45. Schwenger V, Morath C. Immunoadsorption in nephrology and kidney transplantation. Nephrol Dial Transplant. 2010; 25: 2407-2413.

46. Biesenbach P, Kain R, Derfler K, Perkmann T, Soleiman A, Benharkou A, et al. Long-term outcome of antiglomerular basement membrane antibody disease treated with immunoadsorption. PLoS One. 2014; 9: e103568.

47. Henderson SR, Salama AD. Diagnostic and management challenges in Goodpasture’s (anti-glomerular basement membrane) disease Nephrol Dial Transplant. 2017; 28.