Membranoproliferative glomerulonephritis medical therapy: Difference between revisions

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{{CMG}} {{APM}} {{AE}} {{OO}}


Treatment of MPGN
{{Membranoproliferative glomerulonephritis}}
There are three components to the treatment of membranoproliferative glomerulonephritis (MPGN): 
{{CMG}} {{APM}} {{AE}} {{OO}} {{JSS}} {{SAH}}
* Treatment of the underlying cause of the MPGN, (eg, infection);
* assessment of the factors that predict renal prognosis; and
* Treatment of the MPGN, mostly with immunosuppressive drugs.
Treatment of the underlying cause of the MPGN
MPGN due chronic infections should be treated with antivirals, antimicrobials and antiparasitic drugs with drug choice based on the kind of infection. Immunosuppressive therapy is not indicated and may be harmful in cases with MPGN caused by hepatitis B or C <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>.
MPGN due to an autoimmune disease should be treated for the autoimmune disorder. On the contrary, it is essential to treat successfully hepatitis with antiviral agents.
Cryoglobulinemic MPGN should also be treated with antiviral therapy, if associated with HCV infection.
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>.
With all the above treatment, Glomerular filtration Rate should be carefully monitored as a tool to check response to therapy.
Assessment of the factors that predict renal prognosis
Good prognosis is associated with non-nephrotic proteinuria (less than 3.5 g/day, no hypoalbuminemia, and no edema), normal serum creatinine/GFR, and normal blood pressure.
Poor prognostic signs at presentation include evidence of nephrotic syndrome, 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.
Treatment of the MPGN, mostly with immunosuppressive drugs
Indications for immunosuppressive therapy include:
* nephrotic range proteinuria, a
* reduced estimated glomerular filtration,
* and/or severe histologic changes on renal biopsy (eg, crescents)


== Overview ==
The optimal therapy for membranoproliferative glomerulonephritis depends on underlying etiology. In [[Infection|infectious]] and haematological etiology treating the underlying infection will result in resolution of membranoproliferative glomerulonephritis.For [[Autoimmunity|autoimmune]] etiology [[Immunosuppression|immunosuppressive]] agents are given.The treatment also includes [[antihypertensive]] therapy, [[Anticoagulant|anticoagulation therapy]] and  [[Statins|anti-lipid]] therapy for [[Nephrotic syndrome|nephrotic syndrome.]]


== Medical Therapy ==
* Pharmacologic therapy is recommended for patients of membranoproliferative glomerulonephritis.  Treatment options depends upon underlying etiology.<ref name="pmid29852477">{{cite journal| author=Bomback AS, Fervenza FC| title=Membranous Nephropathy: Approaches to Treatment. | journal=Am J Nephrol | year= 2018 | volume= 47 Suppl 1 | issue=  | pages= 30-42 | pmid=29852477 | doi=10.1159/000481635 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29852477  }}</ref><ref name="pmid22859855">{{cite journal| author=Waldman M, Austin HA| title=Treatment of idiopathic membranous nephropathy. | journal=J Am Soc Nephrol | year= 2012 | volume= 23 | issue= 10 | pages= 1617-30 | pmid=22859855 | doi=10.1681/ASN.2012010058 | pmc=3458460 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22859855  }}</ref><ref name="pmid10495797">{{cite journal |vauthors=Wasserstein AG |title=Membranous glomerulonephritis |journal=J. Am. Soc. Nephrol. |volume=8 |issue=4 |pages=664–74 |date=April 1997 |pmid=10495797 |doi= |url=}}</ref><ref name="pmid15847250">{{cite journal |vauthors=Ozsoy RC, Koopman MG, Kastelein JJ, Arisz L |title=The acute effect of atorvastatin on proteinuria in patients with chronic glomerulonephritis |journal=Clin. Nephrol. |volume=63 |issue=4 |pages=245–9 |date=April 2005 |pmid=15847250 |doi= |url=}}</ref>
* Patients with autoimmune etiology are treated with [[immunosuppressive]] therapy.
* Patients with infectious etiology are treated with antivirals or [[Antibiotic|antibiotics]] .
* [[Hepatitis B]] and [[Hepatitis C]] are treated with antivirals.
** [[Leukemia|Leukemias]] and [[Lymphoma|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) [[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'''
:*** '''2.3.1 Life-style modification'''
:**** Decrease salt intake
:**** Weight loss
:*** '''2.3.2 Statins'''
:**** Preferred regimen (1): [[Atorvastatin clinical studies|Atorvastatin]] PO 10mg q daily
==References==
==References==
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Nephrology]]
[[Category:Nephrology]]


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Latest revision as of 20:52, 2 August 2018


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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] Jogeet Singh Sekhon, M.D. [4] Syed Ahsan Hussain, M.D.[5]

Overview

The optimal therapy for membranoproliferative glomerulonephritis depends on underlying etiology. In infectious and haematological etiology treating the underlying infection will result in resolution of membranoproliferative glomerulonephritis.For autoimmune etiology immunosuppressive agents are given.The treatment also includes antihypertensive therapy, anticoagulation therapy and anti-lipid therapy for nephrotic syndrome.

Medical Therapy

  • Pharmacologic therapy is recommended for patients of membranoproliferative glomerulonephritis. Treatment options depends upon underlying etiology.[1][2][3][4]
  • Patients with autoimmune etiology are treated with immunosuppressive therapy.
  • Patients with infectious etiology are treated with antivirals or antibiotics .
  • Hepatitis B and Hepatitis C are treated with antivirals.
  • 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:
  • 2. Treatment for nephrotic sydnrome:

References

  1. Bomback AS, Fervenza FC (2018). "Membranous Nephropathy: Approaches to Treatment". Am J Nephrol. 47 Suppl 1: 30–42. doi:10.1159/000481635. PMID 29852477.
  2. Waldman M, Austin HA (2012). "Treatment of idiopathic membranous nephropathy". J Am Soc Nephrol. 23 (10): 1617–30. doi:10.1681/ASN.2012010058. PMC 3458460. PMID 22859855.
  3. Wasserstein AG (April 1997). "Membranous glomerulonephritis". J. Am. Soc. Nephrol. 8 (4): 664–74. PMID 10495797.
  4. Ozsoy RC, Koopman MG, Kastelein JJ, Arisz L (April 2005). "The acute effect of atorvastatin on proteinuria in patients with chronic glomerulonephritis". Clin. Nephrol. 63 (4): 245–9. PMID 15847250.

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