Immunosuppressive Therapy and Supportive Care

Immunosuppressive Regimens

High-dose corticosteroids, such as prednisone 1 mg/kg/day, are recommended with gradual taper over 6 months, according to the Kidney International guideline 1
High-dose glucocorticoids and cyclophosphamide may be considered as a treatment option for patients with severe kidney disease, according to the American Journal of Kidney Diseases 2
Calcineurin inhibitors may be used for steroid resistance, as suggested by the American Journal of Kidney Diseases 3
Initial immunosuppression with cyclophosphamide and corticosteroids may be considered for pauci-immune glomerulonephritis, followed by maintenance therapy with azathioprine for at least 18 months, as recommended by the American College of Physicians 3, 4
Rituximab can be used as an alternative to cyclophosphamide, especially for patients with contraindications, at a dose of 375 mg/m² weekly for 4 weeks or 1000 mg on days 1 and 15 3, 4

ACE inhibitors or ARBs are recommended at maximally tolerated doses for patients with hypertension and proteinuria, with a target systolic BP <120 mmHg in most adult patients, as suggested by the Kidney International and American Heart Association guidelines 1
Statin therapy is suggested for persistent dyslipidemia, particularly in patients with other cardiovascular risk factors, as recommended by the Kidney International guideline 1
Dietary sodium restriction (<2.0 g/day) is recommended, along with diuretics as first-line therapy, and if diuretic response is insufficient, add mechanistically different diuretics with careful monitoring for adverse effects, as suggested by the Kidney International guideline 1, 5
Limiting dietary sodium intake is recommended to help control edema and hypertension, as suggested by the National Kidney Foundation 3, 1

Treating the underlying infection is recommended, with penicillin or erythromycin for 10 days for post-streptococcal GN, and appropriate antibiotics for 4-6 weeks for infective endocarditis, as suggested by the American Journal of Kidney Diseases 3
Antibiotic therapy with Penicillin (or erythromycin if penicillin-allergic) is recommended to eliminate remaining streptococcal organisms in post-streptococcal glomerulonephritis (PSGN), with a standard duration of 10 days 3
Pneumococcal vaccine is recommended for patients with glomerular disease, nephrotic syndrome, or CKD, as well as influenza vaccine for patients and household contacts, and herpes zoster vaccination (Shingrix), as recommended by the Centers for Disease Control and Prevention 5
Prophylactic trimethoprim-sulfamethoxazole should be considered for patients on high-dose prednisone, rituximab, or cyclophosphamide, and screening for Strongyloides in patients from endemic areas with eosinophilia and elevated IgE before immunosuppression is recommended 5

Azathioprine is recommended as first-line maintenance therapy at a dose of 1-2 mg/kg/day orally, for at least 18 months after achieving remission, as suggested by the American Journal of Kidney Diseases and American College of Physicians 3, 4
Mycophenolate mofetil (MMF) or methotrexate can be used as alternatives if intolerant to azathioprine, at doses of up to 1 g twice daily or 0.3 mg/kg/week, respectively 3, 4
Regular monitoring of renal function tests, urinalysis, ANCA levels, and signs of disease activity in other organ systems is recommended, as suggested by the American Journal of Kidney Diseases and American College of Physicians 3, 4
Kidney biopsy is the gold standard for diagnosis of glomerular diseases, evaluating urine sediment, proteinuria, and assessing kidney function in adults and children, as recommended by the Kidney International guideline and American Journal of Kidney Diseases 5, 1

Protein restriction based on proteinuria level and kidney function is recommended, with a target intake of 0.8-1 g/kg/day for patients with nephrotic-range proteinuria, and 0.8 g/kg/day for patients with eGFR <60 ml/min/1.73 m² and nephrotic-range proteinuria, as suggested by the American Journal of Kidney Diseases 5
Plant-based protein sources are preferred, with a target caloric intake of 35 kcal/kg/day (30-35 kcal/kg/day if eGFR <60) 5