Management of Chronic Glomerulonephritis

Diagnostic Evaluation

Kidney biopsy remains the "gold standard" for diagnostic evaluation of glomerular diseases, and repeat kidney biopsy should be performed only if it will potentially alter the diagnosis, therapeutic plan, or contribute to the estimation of prognosis, according to Kidney International 2, 3
Assess total urinary protein excretion with a 24-hour urine collection in adults, and first morning protein-creatinine ratio (PCR) is more appropriate in children, as recommended by Kidney International 2, 4
Use CKD-EPI creatinine equation to assess eGFR in adults and modified Schwartz equation in children, as suggested by Kidney International 2
Perform routine evaluation of urine sediment for erythrocyte morphology and the presence of red cell casts and/or acanthocytes, according to Kidney International 2

Choose a treatment regimen that averts immediate morbidity of the primary disease process, and the intensity of induction therapy should be based on the severity of presenting symptoms and type of glomerulonephritis, as recommended by Kidney International 2
Complete clinical remission may not be possible in all forms of chronic glomerulonephritis, and prolonged immunosuppression or multiple rounds of immunosuppression may be required to prevent or delay CKD progression, according to Kidney International 2
Proteinuria reduction is a surrogate endpoint in the treatment of glomerulonephritis, as suggested by Kidney International 2

Use ACE inhibitors or ARBs at maximally tolerated doses as first-line therapy for patients with both hypertension and proteinuria, and target systolic blood pressure <120 mmHg in most adult patients, as recommended by Praxis Medical Insights 1
In children, target 24-hour mean arterial pressure at ≤50th percentile for age, sex, and height, according to Praxis Medical Insights 1
Hold RAS inhibitors during intercurrent illnesses with risk of volume depletion, as suggested by Praxis Medical Insights 1

Restrict dietary sodium to <2.0 g/day to reduce edema, control blood pressure, and help manage proteinuria, as recommended by Kidney International and Praxis Medical Insights 5, 1
Use diuretics as first-line agents for edema management, and add mechanistically different diuretics if response is insufficient, according to Kidney International 4
Monitor for adverse effects of diuretics including hyponatremia, hypokalemia, GFR reduction, and volume depletion, as suggested by Kidney International 4

Adjust protein intake based on degree of proteinuria and kidney function, and restrict dietary fats in patients with elevated serum cholesterol, as recommended by Kidney International 5
Target caloric intake 35 kcal/kg/day, and for eGFR <60 ml/min/1.73 m², limit to 30-35 kcal/kg/day, according to Kidney International 5

Immunosuppression is reserved for specific types of glomerulonephritis and cases with severe or progressive disease, and adjust doses of immunosuppressants according to patient age and eGFR, as recommended by Praxis Medical Insights 1

Screen for latent infections prior to initiating immunosuppression, and monitor therapeutic drug levels where clinically indicated, as suggested by Praxis Medical Insights 1
Review vaccination status and update as required before starting immunosuppression, and consider fertility preservation where indicated, according to Praxis Medical Insights 1
Monitor for development of cancers or infections during immunosuppressive therapy, as recommended by Praxis Medical Insights 1

Assess proteinuria regularly, and reduction in proteinuria is a marker of treatment response, as suggested by Praxis Medical Insights 1
Monitor for a ≥40% decline in eGFR from baseline over 2-3 years as a surrogate outcome measure for kidney failure, according to Praxis Medical Insights 1
Perform repeat kidney biopsy only if the patient has rapidly deteriorating kidney function, as recommended by Praxis Medical Insights 1

The primary focus of management should be optimized supportive care, and assess cardiovascular risk and commence appropriate interventions, as recommended by Kidney International 5
Give lifestyle advice, including information on dietary sodium restriction, smoking cessation, weight control, and exercise, according to Kidney International 5
Variant forms of IgAN may require specific immediate treatment, as suggested by Kidney International 5

Avoid protein restriction <0.6 g/kg/day due to safety concerns and risk of malnutrition, as recommended by Kidney International 5
The safety of protein restriction in GN has not been established in children, according to Kidney International 5