Membranoproliferative glomerulonephritis medical therapy: Difference between revisions

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Revision as of 20:24, 27 July 2018

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]

Overview

Medical Therapy

Pharmacologic medical therapy is recommended for patients of membranoproliferative glomerulonephritis.
The treatment depends on the cause of the disease.
Patients with autoimmuneetiology are treated with immunosuppressive therapy
Patients with infectious etiology are treated with antivirals or antibiotics depending on the cause.
Hepatitis B and Hepatitis C are treated with antivirals.
Leukemias and lymphomas treated with chemotherapy.
Other pharmacologic medical therapies for membranoproliferative glomerulonephritis include antihypertensive therapy, anticoagulation therapy and anti-lipid therapy.

1. Patients with autoimmune etiology

1.1 Immunosuppressive therapy:

Preferred regimen (1): Prednisone 0.5 mg/kg per day with cyclophosphamide IV for 3-5 months
Preferred regimen (2): Methylprednisolone 0.4 mg/kg per day given with cyclophosphamide 2.0 to 2.5 mg/kg per day given IV for 2, 4, and 6 months
Preferred regimen (3): Tacrolimus 0.05 mg/kg per day for PO for 12 months with a six-month taper
Preferred regimen (4): Rituximab 3.5g/day IV for 6-12 months

2. Treatment for nephrotic sydnrome:

2.1 Antihypertensive therapy

Preferred regimen (1) Losartan PO for 50 mg q daily (100mg per day)

2.2 Anticoalgulation tharapy

Low molecular weight or unfractionated heparin, followed by PO warfarin.

2.3 Anti-lipid therapy

2.3.1 Life-style modification

Decrease salt intake
Weight loss

2.3.2 Statins

Atorvastatin PO 10mg q daily

References

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@@ Line 7: / Line 7: @@
 == Medical Therapy ==
-There are three factors to consider the treatment of membranoproliferative glomerulonephritis (MPGN):
+* Pharmacologic medical therapy is recommended for patients of membranoproliferative glomerulonephritis.
-*	Identify the underlying cause of the MPGN, (e.g. lupus, infection, disorders of the complement pathway, or ideopathic MPGN);
+* The treatment depends on the cause of the disease.
-*	Asses the factors that predict renal prognosis (e.g. degree of proteinuria, age, comorbidities); and
+* Patients with [[Autoimmune|autoimmuneetiology]]  are treated with [[immunosuppressive]] therapy
-*	 Treat the underlying cause of the MPGN,
+* Patients with infectious etiology are treated with antivirals or antibiotics depending on the cause.
+* Hepatitis B and Hepatitis C are treated with antivirals.
+* Leukemias and lymphomas treated with chemotherapy.
+* Other pharmacologic medical therapies for membranoproliferative glomerulonephritis include [[antihypertensive]] therapy, anticoagulation therapy and  anti-lipid therapy.
+'''1. Patients with autoimmune etiology'''
-Treatment of the underlying cause of the MPGN
+'''1.1 Immunosuppressive therapy:'''
+:* Preferred regimen (1): [[Prednisone]] 0.5 mg/kg per day with [[cyclophosphamide]] IV for 3-5 months
+:* Preferred regimen (2): [[Methylprednisolone]] 0.4 mg/kg per day given with [[cyclophosphamide]] 2.0 to 2.5 mg/kg per day given IV for 2, 4, and 6 months
+:* Preferred regimen (3): [[Tacrolimus]] 0.05 mg/kg per day for PO for 12 months with a six-month taper
+:* Preferred regimen (4): [[Rituximab]] 3.5g/day IV for 6-12 months
+'''2. Treatment for nephrotic sydnrome:'''
-Once the underlying cause of the MPGN is identified, therapy should be targeted accordingly.
+'''2.1 Antihypertensive therapy'''
+:* Preferred regimen (1) [[Angiotensin|Losartan]] PO for 50 mg q daily (100mg per day)
+'''2.2 Anticoalgulation tharapy'''
+:* [[Heparin|Low molecular weight or unfractionated heparin]], followed by PO [[warfarin]].
+'''2.3 Anti-lipid therapy'''
-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>.
+'''2.3.1 Life-style modification'''
+:* Decrease salt intake
-See therapy for: Hepatitis B, Hepatitis C,.....
+:* Weight loss
+'''2.3.2 Statins'''
-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.
+:* [[Atorvastatin clinical studies|Atorvastatin]] PO 10mg q daily
+:
-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:
-*	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.

Membranoproliferative glomerulonephritis medical therapy: Difference between revisions

Revision as of 20:24, 27 July 2018

Overview

Medical Therapy

References

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