Management of Immune Complex Mediated Glomerulonephritis

Diagnostic Evaluation

The American Journal of Kidney Diseases recommends evaluating all patients with ICGN for underlying diseases including infections and autoimmune disorders before initiating treatment 1
Comprehensive complement analysis should be performed to assist with diagnosis, even in the absence of hypocomplementemia, as recommended by the American Journal of Kidney Diseases 1
Screening for paraproteins with serum and urine electrophoresis, immunofixation, and free light chain analysis is recommended when monoclonal immunoglobulin deposits are found, according to the American Journal of Kidney Diseases 1
Patients ≥50 years with C3 glomerulopathy should be evaluated for the presence of monoclonal proteins, as suggested by the American Journal of Kidney Diseases 1

For indolent ICGN, the American Journal of Kidney Diseases recommends providing supportive therapy with RAS inhibition alone 1
The Kidney International suggests treating ICGN with nephrotic syndrome but stable kidney function with direct-acting antivirals (DAAs) prior to other treatments if HCV-associated 2
For rapidly progressive glomerulonephritis or cryoglobulinemic flare, the Kidney International recommends initiating combined therapy with both DAAs and immunosuppressive agents with or without plasma exchange for HCV-associated cases 2
The American Journal of Kidney Diseases suggests using cyclophosphamide and corticosteroids plus plasmapheresis for non-HCV related cases with severe presentation 4

For HCV-associated ICGN, the Kidney International recommends first-line treatment with DAAs without dose adjustment 2
The Kidney International suggests using DAAs plus immunosuppression with or without plasma exchange for cryoglobulinemic flare or rapidly progressive disease 2
For persistent disease despite DAA therapy, the Kidney International recommends rituximab as first-line immunosuppressive agent 2

Access to plasmapheresis may be limited in some healthcare systems, and this should be factored into the urgency of diagnostic workup, as noted by the American Journal of Kidney Diseases 4
The American Journal of Kidney Diseases suggests considering mycophenolic acid as a cost-effective substitute for MMF in healthcare systems where coverage differs 4