Modern classification, progression factors, treatment and outcomes of primary mesangial proliferative glomerulonephritis

Abstract

The choice of treatment of mesangial proliferative glomerulonephritis (post-infection, immunoglobulin A, G and M nephritis) is performed taking into account the remission achievement, slowing of progression and reduction of the risk of recurrences of glomerulonephritis. The efficiency of etiologic factor removing is debatable: glomerulonephritis associated with infections usually resolves after their elimination; individual patients achieve immunoglobulin A nephritis remission with persistent antimicrobial treatment of focal infection, but surgical removal of the focus (tonsillectomy) does not affect the long-term prognosis, therefore it is not recommended. Treatment of immunoglobulin A nephritis with oral prednisone for up to 4 months, sometimes in combination with cyclophosphamide (cyclophosphane), reduces the likelihood of its relapse. At low risk of progression of immunoglobulin A nephritis with proteinuria less than 1 g/day, long-term therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers is indicated with administration of maximum tolerated doses for proteinuria more than 1 g/day. Also fish oil 3 g/day is administered for up to 2 years. If proteinuria more than 1 g/day persists for 3-6 months, corticosteroids are recommended for 6 months. With mild renal dysfunction, corticosteroids are prescribed orally or in pulse-therapy with high doses intravenously and maintenance therapy with low doses orally. Immunosuppressive therapy - cyclophosphamide, cyclosporine, azathioprine, mycophenolate mofetil - in combination with corticosteroids is indicated in rapid loss of renal function or massive/moderate proteinuria. In minimal proteinuria immunosuppressive therapy is considered to be unreasonable. Use of intravenous immunoglobulin for immunoglobulin A nephritis from the point of view of lesser toxic effect is possible only as the induction therapy. Currently, there are no clinical recommendations for the treatment of immunoglobulin M nephritis, in case of nephrotic syndrome, corticosteroids are the drugs of the 1st line. There are isolated studies of the use of cyclophosphamide, mycophenolate mofetil, and cyclosporine, with the achievement of remission in frequent relapses of nephrotic syndrome or steroid drug resistance. The cases of immunoglobulin M nephritis treates with retuximab with a positive effect are described. The effectiveness of immunoglobulin G nephritis treatment is less studied, the choice of treatment is similar to that of immunoglobulin A and M nephritis.