Glomerulonephritis is an immune lesion of the kidney glomeruli.
By the nature of the course of glomerulonephritis is acute and chronic.
- Infections ( angina, scarlet fever, infective endocarditis, sepsis, pneumococcal pneumonia, typhoid fever, meningococcal infection, viral hepatitis B, infectious mononucleosis, epidemic parotitis, chickenpox , infections caused by Koksaki viruses, etc.)
- Systemic diseases: systemic red lupus , vasculitis, Schönlein-Genoha disease, hereditary pulmonary renal syndrome
- Introduction of vaccines, serums
- Toxic substances (organic solvents, alcohol, mercury, lead, etc.)
- Irradiation, etc.
Glomerulonephritis manifests itself in 1-4 weeks. after exposure to a provoking factor.
- Blood in the urine – urine colors “meat slop”
- Swelling of the face (especially the eyelids), as well as feet and legs
- Blood pressure increase
- Decreased urine, thirst
- Increased body temperature (rare)
- Lack of appetite, nausea, vomiting, headache weakness
- Weight gain
Depending on the various forms of glomerular lesion, one or other manifestations of glomerulonephritis may prevail.
Acute glomerulonephritis develops 6-12 days after the infection, usually streptococcal (angina, tonsillitis, scarlet fever), including skin ( pyoderma, impetigo ).
The disease can also develop after other infections – bacterial, viral, parasitic, as well as after other antigenic effects – serum, vaccines, drugs.
In the classic cyclic course, acute glomerulonephritis is characterized by changes in urine (red urine due to blood admixture), swelling, and a decrease in the amount of urine released.
- General urine analysis. In the urine – red blood cells, white blood cells , cylinders, protein
- Urine specific gravity normal or elevated
- Increased titer of antibodies to streptococcus in the blood ( antistreptolysin-O , antistreptokinase, antihyaluronidase)
- Decrease in the content of the components of complement SZ, C4 in the serum with a return to the initial level in 6-8 weeks with post-streptococcal acute glomerulonephritis; with membranoproliferative glomerulonephritis, these changes persist for life
- The content of total protein in serum is reduced, in the proteinogram – an increase in a1-and a2-globulins
- Ultrasound of the kidneys
- Radioisotope angiorenography
- Ocular fundus
- Renal biopsy allows to clarify the morphological form of chronic glomerulonephritis, its activity, to exclude kidney diseases with similar symptoms
Treatment of glomerulonephritis
- Hospitalization in the nephrology department
- Bed rest
- Diet number 7a: restriction of proteins, salt limit edema, hypertension
Antibiotics (for acute post-streptococcal glomerulonephritis or the presence of foci of infection)
Immunosuppressants and glucocorticoids are ineffective in post-infectious, post-streptococcal acute glomerulonephritis.
Immunosuppressive therapy – glucocorticoids and cytotoxic drugs – in case of exacerbation of chronic glomerulonephritis.
shown in mesangioproliferative chronic glomerulonephritis and chronic glomerulonephritis with minimal glomerular changes. With membranous chronic glomerlonephritis, the effect is not clear.
With membranoproliferative chronic glomerulonephritis and focal segmental glomerulosclerosis, glucocorticoids are ineffective.
administered on 1 mg / kg / day orally for 6-8 weeks, followed by a rapid decrease to 30 mg / day (5 mg / week), and then slow (2.5-1.25 mg / week) up to full cancellation.
Pulse therapy with prednisolone is carried out with a high activity of CGN in the first days of treatment – 1000 mg IV drip 1 r / day for 3 days in a row. After reducing the activity of chronic glomerulonephritis, monthly pulse therapy is possible until remission is achieved.
- cyclophosphamide at 2-3 mg / kg / day by mouth or intramuscularly or intravenously,
- chlorambucil 0.1-0.2 mg / kg / day inside,
as alternative drugs:
- Cyclosporine – 2.5-3.5 mg / kg / day, inside,
- azathioprine 1.5-3 mg / kg / day inside)
they are indicated in active forms of chronic glomerulonephritis with a high risk of progression of renal failure, as well as in the presence of contraindications for the administration of glucocorticoids, inefficiency or complications when using the latter (in the latter case, they prefer the combined use of glucocorticoids).
Pulse therapy with cyclophosphamide is indicated for high activity of chronic glomerulonephritis, either in combination with pulse therapy with prednisolone (or against the background of daily administration of prednisolone), or in isolation without additional prescription of prednisolone; in the latter case, the dose of cyclophosphamide should be 15 mg / kg (or 0.6-0.75 g / m2 of body surface) i / v monthly:
Multicomponent treatment regimens
Simultaneous use of glucocorticoids and cytostatics is considered more effective monotherapy with glucocorticoids. It is generally accepted to prescribe immunosuppressive drugs in combination with antiplatelet agents, anticoagulants – the so-called multi-component schemes:
scheme (without cytostatics): prednisone 1 – 1.5 mg / kg / day by mouth 4-6
weeks, then 1 mg / kg / day every other day, then reduced by 1.25-2.5 mg / week
to cancellation + heparin in 5000 IU 4 p / day for 1 -2 months with a switch to
phenyldione or acetylsalicylic acid in a dose of 0.25-0.125 g / day, or
sulodexide in a dose of 250 ME 2 times / day orally + 400 mg dipyridamole / day
inside or in / in.
scheme Kinkayd-Smith: prednisone 25-30 mg / day orally for 1-2 months, then
reduce the dose by 1.25-2.5 mg / week until discontinuation + Cyclophosphamide
100-200 mg for 1 – 2 months, then half dose to achieve remission
(cyclophosphamide can be replaced with chlorambucil or azathioprine) + Heparin
5000 U, 4 p / day for 1-2 months with switching to phenyldione or
acetylsalicylic acid, or sulodexide + Dipyridamole 400 mg / day inside or in /
scheme: initiation of therapy with prednisolone – 3 days in a row at 1000 mg /
day, the next 27 days prednisone 30 mg / day by mouth, the 2nd month – chlorambucil 0.2
mg / kg (alternation of prednisolone and chlorbutin).
- Steinberg scheme – pulse therapy with cyclophosphamide: 1000 mg IV monthly for a year. In the next 2 years – 1 time in 3 months. In the next 2 years – 1 time in 6 months.
Antihypertensive therapy: captopril 50-100 mg / day, enalapril 10-20 mg / day, ramipril 2.5-10 mg / day
Diuretics – hydrochlorothiazide, furosemide, spironolactone
Antioxidant therapy (vitamin E), however, there is no convincing evidence of its effectiveness.
Lipid-lowering drugs (nephrotic syndrome): simvastatin, lovastatin, fluvastatin, atorvastatin in a dose of 10-60 mg / day for 4-6 weeks with a subsequent decrease in dose.
Antiplatelet agents (in combination with glucocorticoids, cytostatics, anticoagulants; see above). Dipyridamole 400-600 mg / day. Pentoxifylline at 0.2-0.3 g / day. Ticlopidine 0.25 g 2 p / day
Plasma exchange in combination with pulse therapy with prednisolone and / or cyclophosphamide is indicated for highly active chronic glomerulonephritis and the lack of effect of treatment with these drugs.
Surgery. Kidney transplantation in 50% is complicated by relapse in the graft, in 10% by graft rejection.
Mesangioproliferative chronic glomerulonephritis
With slowly progressive forms, incl. with IgA nephritis, there is no need for immunosuppressive therapy. At high risk of progression – glucocorticoids and / or cytostatics – 3-and 4-component schemes. The effect of immunosuppressive therapy on the long-term prognosis remains unclear.
Membranous chronic glomerulonephritis
The combined use of glucocorticoids and cytostatics. Pulse therapy with cyclophosphamide 1000 mg IV monthly. In patients without nephrotic syndrome and normal renal function, they are ACE inhibitors.
Membranoproliferative (mesangiocapillary) chronic glomerulonephritis
Treatment of the underlying disease. ACE inhibitors. In the presence of nephrotic syndrome and reduced renal function, therapy with glucocorticoids and cyclophosphamide with the addition of antiplatelet agents and anticoagulants is justified.
Chronic glomerulonephritis with minimal changes
Prednisone 1 to 1.5 mg / kg for 4 weeks, then 1 mg / kg every other day for another 4 weeks. Cyclophosphamide or chlorambucil with the ineffectiveness of prednisone or the inability to cancel it due to relapses. With continuing relapses of nephrotic syndrome – cyclosporine 3-5 mg / kg / day (children 6 mg / m2) 6-12 months after achieving remission.
Focal segmental glomerulosclerosis
Immunosuppressive therapy is not effective enough. Glukokrkoikoid prescribed for a long time – up to 16-24 weeks. Patients with nephrotic syndrome are prescribed prednisone for 1–1.2 mg / kg daily for 3-4 months, then every other day for 2 months, then reduce the dose until canceled. Cytostatics (cyclophosphamide, cyclosporine) in combination with glucocorticoids.
Fibroplastic chronic glomerulonephritis
In the focal process, treatment is carried out according to the morphological form that led to its development. Diffuse form – a contraindication to active immunosuppressive therapy.
Treatment according to clinical forms is carried out when it is impossible to perform a biopsy of the kidneys.
- Latent form of glomerulonephritis. Active immunosuppressive therapy is not indicated. When proteinuria> 1.5 g / day prescribed ACE inhibitors.
- Hematuric form of glomerulonephritis. Intermittent effect of prednisone and cytostatics. Patients with isolated hematuria and / or small proteinuria are ACE inhibitors and dipyridamole.
- Hypertensive form of glomerulonephritis. ACE inhibitors; target level of blood pressure – 120-125 / 80 mm Hg. For exacerbations, cytostatics are used as part of a 3-component scheme. Glucocorticoids (prednisone 0.5 mg / kg / day) can be administered as monotherapy or as part of a combination regimen.
- Nephrotic form of glomerulonephritis – indication for the purpose of a 3-or 4-component scheme
- Mixed form – 3 or 4-component treatment regimen.