Membranoproliferative glomerulonephritis medical therapy: Difference between revisions
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{{CMG}} {{APM}} {{AE}} {{OO}} | {{CMG}} {{APM}} {{AE}} {{OO}} | ||
There are three factors to consider the treatment of membranoproliferative glomerulonephritis (MPGN): | |||
There are three | * Identify the underlying cause of the MPGN, (e.g. lupus, infection, disorders of the complement pathway, or ideopathic MPGN); | ||
* | * Asses the factors that predict renal prognosis (e.g. degree of proteinuria, age, comorbidities); and | ||
* | * Treat the underlying cause of the MPGN, | ||
* | |||
Treatment of the underlying cause of the MPGN | Treatment of the underlying cause of the MPGN | ||
MPGN due | |||
Once the underlying cause of the MPGN is identified, therapy should be targeted accordingly. | |||
MPGN due infections should target the causative pathogen. This can include antivirals, antimicrobials and antiparasitic drugs. Immunosuppressive therapy is contraindicated and can be harmful in cases of hepatitis B or C mediated MPGN<ref name="pmid21757949">{{cite journal| author=Sandri AM, Elewa U, Poterucha JJ, Fervenza FC| title=Treatment of hepatitis C-mediated glomerular disease. | journal=Nephron Clin Pract | year= 2011 | volume= 119 | issue= 2 | pages= c121-9; discussion c129-30 | pmid=21757949 | doi=10.1159/000325220 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21757949 }} </ref>. | |||
See therapy for: Hepatitis B, Hepatitis C,..... | |||
MPGN due to an autoimmune disease should target the primary disorder and should take into consideration patients age, severity of kidney involvement, and other organ involvements. | |||
See therapy for lupus nephritis, ideopathic cryglobulinemia, paraprotein related kidney disease, C3 glomerulonephritis.... | |||
Rituximab has been also used in cases with MPGN associated with a monoclonal gammopathy and it gave a long-lasting complete or partial remissions in 7/8 cases<ref name="pmid21700823">{{cite journal| author=Guiard E, Karras A, Plaisier E, Duong Van Huyen JP, Fakhouri F, Rougier JP et al.| title=Patterns of noncryoglobulinemic glomerulonephritis with monoclonal Ig deposits: correlation with IgG subclass and response to rituximab. | journal=Clin J Am Soc Nephrol | year= 2011 | volume= 6 | issue= 7 | pages= 1609-16 | pmid=21700823 | doi=10.2215/CJN.10611110 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21700823 }} </ref>. Also, rituximab has been shown effective in the treatment of MPGN associated with chronic lymphocytic leukemia <ref name="pmid18397703">{{cite journal| author=Bartel C, Obermüller N, Rummel MJ, Geiger H, Hauser IA| title=Remission of a B cell CLL-associated membranoproliferative glomerulonephritis Type I with rituximab and bendamustine. | journal=Clin Nephrol | year= 2008 | volume= 69 | issue= 4 | pages= 285-9 | pmid=18397703 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18397703 }} </ref>. | |||
Ideopathic MPGN: Indications for immunosuppressive therapy include: | |||
Indications for immunosuppressive therapy include: | |||
* nephrotic range proteinuria, a | * nephrotic range proteinuria, a | ||
* reduced estimated glomerular filtration, | * reduced estimated glomerular filtration, | ||
* and/or severe histologic changes on renal biopsy (eg, crescents) | * and/or severe histologic changes on renal biopsy (eg, crescents) | ||
Treatment of ideopathic MPGN includes (xxx) | |||
with immunosuppressive drugs | |||
With all the above treatment, Blood pressure, eGFR, proteinuria, and hematuria should be carefully monitored as a tool to check response to therapy. Follow up biopsy may be done in select case to evaluate for response, prognosis, and transformation of disease (e.g change in lupus nephritis class) | |||
Assessment of the factors that predict renal prognosis: | |||
In general, non-nephrotic range proteinuria (less than 3.5 g/day) and lack of nephrotic syndrome (no hypoalbuminemia, no hyperlipidemia), normal serum creatinine/GFR, and normal blood pressure are all associated with a better prognosis. | |||
Poor prognostic signs at presentation include evidence of nephrotic and nephritic syndrome, including elevated serum creatinine, hypertension plus hematuria. Bad prognosis is also associated with Idiopathic MPGN and signs of tubulointerstitial disease (interstitial inflammation, fibrosis, and tubular atrophy) which correspond to great glomerular damage. | |||
Revision as of 14:18, 28 November 2016
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Ali Poyan Mehr, M.D. [2] Associate Editor(s)-in-Chief: Olufunmilola Olubukola M.D.[3]
There are three factors to consider the treatment of membranoproliferative glomerulonephritis (MPGN):
- Identify the underlying cause of the MPGN, (e.g. lupus, infection, disorders of the complement pathway, or ideopathic MPGN);
- Asses the factors that predict renal prognosis (e.g. degree of proteinuria, age, comorbidities); and
- Treat the underlying cause of the MPGN,
Treatment of the underlying cause of the MPGN
Once the underlying cause of the MPGN is identified, therapy should be targeted accordingly.
MPGN due infections should target the causative pathogen. This can include antivirals, antimicrobials and antiparasitic drugs. Immunosuppressive therapy is contraindicated and can be harmful in cases of hepatitis B or C mediated MPGN[1].
See therapy for: Hepatitis B, Hepatitis C,.....
MPGN due to an autoimmune disease should target the primary disorder and should take into consideration patients age, severity of kidney involvement, and other organ involvements.
See therapy for lupus nephritis, ideopathic cryglobulinemia, paraprotein related kidney disease, C3 glomerulonephritis....
Rituximab has been also used in cases with MPGN associated with a monoclonal gammopathy and it gave a long-lasting complete or partial remissions in 7/8 cases[2]. Also, rituximab has been shown effective in the treatment of MPGN associated with chronic lymphocytic leukemia [3].
Ideopathic MPGN: Indications for immunosuppressive therapy include:
- nephrotic range proteinuria, a
- reduced estimated glomerular filtration,
- and/or severe histologic changes on renal biopsy (eg, crescents)
Treatment of ideopathic MPGN includes (xxx)
with immunosuppressive drugs
With all the above treatment, Blood pressure, eGFR, proteinuria, and hematuria should be carefully monitored as a tool to check response to therapy. Follow up biopsy may be done in select case to evaluate for response, prognosis, and transformation of disease (e.g change in lupus nephritis class)
Assessment of the factors that predict renal prognosis:
In general, non-nephrotic range proteinuria (less than 3.5 g/day) and lack of nephrotic syndrome (no hypoalbuminemia, no hyperlipidemia), normal serum creatinine/GFR, and normal blood pressure are all associated with a better prognosis. Poor prognostic signs at presentation include evidence of nephrotic and nephritic syndrome, including elevated serum creatinine, hypertension plus hematuria. Bad prognosis is also associated with Idiopathic MPGN and signs of tubulointerstitial disease (interstitial inflammation, fibrosis, and tubular atrophy) which correspond to great glomerular damage.
References
- ↑ Sandri AM, Elewa U, Poterucha JJ, Fervenza FC (2011). "Treatment of hepatitis C-mediated glomerular disease". Nephron Clin Pract. 119 (2): c121–9, discussion c129-30. doi:10.1159/000325220. PMID 21757949.
- ↑ Guiard E, Karras A, Plaisier E, Duong Van Huyen JP, Fakhouri F, Rougier JP; et al. (2011). "Patterns of noncryoglobulinemic glomerulonephritis with monoclonal Ig deposits: correlation with IgG subclass and response to rituximab". Clin J Am Soc Nephrol. 6 (7): 1609–16. doi:10.2215/CJN.10611110. PMID 21700823.
- ↑ Bartel C, Obermüller N, Rummel MJ, Geiger H, Hauser IA (2008). "Remission of a B cell CLL-associated membranoproliferative glomerulonephritis Type I with rituximab and bendamustine". Clin Nephrol. 69 (4): 285–9. PMID 18397703.