eMedicine Specialties > Nephrology > Glomerular Diseases

Glomerulonephritis, Nonstreptococcal Associated With Infection: Treatment & Medication

Author: James W Lohr, MD, Fellowship Program Director, Professor, Department of Internal Medicine, Division of Nephrology, State University of New York at Buffalo
Coauthor(s): Quresh T Khairullah, MBBS, Consulting Staff, Department of Medicine, Division of Nephrology, St John's Hospital and Medical Center
Contributor Information and Disclosures

Updated: Dec 15, 2008

Treatment

Medical Care

In most cases, the treatment of glomerulonephritis (GN) associated with infection is based on treating the underlying infection. In certain instances, immunosuppressive agents such as corticosteroids may be employed to reduce glomerular inflammation.

  • Viral  
    • Chronic hepatitis B: Treatment is indicated if associated liver dysfunction is present. The usual regimen is interferon alfa-2b at 5 million U/d for 4 months or 10 million U 3 times a week for 4 months. The efficacy of pegylated interferon in regard to hepatitis B related renal disease is unclear at this time. Entecavir and lamivudine have also been used in patients with hepatitis B and GN.
    • Chronic hepatitis C: Treatment is with recombinant human interferon alfa at 3 million U 3 times a week for 24 weeks. The pegylated form is long acting and slightly more effective. Preferably, interferon is given along with ribavirin, but this cannot be given in the presence of renal insufficiency. Rituximab has been used to treat hepatitis C related glomerulopathy.
    • HIV: Highly active antiretroviral therapy (HAART) is the standard of care for patients with HIV, with or without nephropathy. Treatment is based on findings from viral titers, the history of previous therapy, and, preferably, on the advice of an infectious diseases specialist. There is evidence that HAART therapy may slow the progression of HIV associated nephropathy to end-stage renal disease. Patients should also be started on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), as this may slow the progression of disease.
    • Other viral agents: Cytomegalovirus, parvovirus, and polyomavirus associated nephropathy are observed in immunocompromised individuals and those who have undergone renal transplantation. Treatment is with specific antiviral agents (ie, ganciclovir for cytomegalovirus and cidofovir for polyomavirus [JC and BK virus]) and temporary withdrawal of immunosuppression therapy.
  • Syphilis: Nephropathy is usually observed in secondary syphilis because this phase is associated with high levels of immune complexes. If CNS or ocular involvement is not present, treatment is similar to primary syphilis (ie, single IM dose of benzathine penicillin 2.4 million U). If the patient is allergic to penicillin, use doxycycline (100 mg PO bid) or erythromycin (500 mg PO qid) for 2 weeks.
  • Endocarditis: Treatment of shunt infections and visceral abscesses is usually is based on culture sensitivity results.
  • Paracytic
    • Malaria: Even though falciparum malaria can cause acute tubular necrosis due to acute hemolysis, hypotension chronic-progressive nephropathy is observed with Plasmodium malariae infection. In comparison with falciparum malaria, P malariae infection is a more indolent form of infection, which affects only 25% of erythrocytes and tends to cause chronic progressive immune complex–mediated nephropathy. Treatment with chloroquine is effective for P malariae infection because resistance is uncommon. However, treatment of the infection does not usually slow the progression of nephropathy, and most patients progress to end-stage renal disease in 3-5 years.
    • Schistosomiasis: Usually, treatment with praziquantel does not slow the progression of nephropathy. Sometimes, if schistosomiasis is associated with co-infection with Salmonella species, treatment of the Salmonella infection improves the nephropathy.
    • Others: Agents used in leishmaniasis treatment include antimony compounds (eg, sodium stibogluconate) and amphotericin B, pentamidine, and paromomycin. Diethylcarbamazepine and ivermectin are used for treating filariasis.
  • Fungal: For aspergillosis, treatment is based on the site of infection and usually includes amphotericin.

Surgical Care

If bacterial endocarditis or a shunt infection does not respond to antibiotics, then surgical intervention is indicated.

Consultations

  • Consultation with a nephrologist is indicated in patients with GN associated with infection.
  • Consultation with an infectious diseases specialist may be appropriate if the infectious etiology is unclear.

Diet

  • Salt restriction for is indicated for patients with hypertension.

Activity

  • Activity can be performed as tolerated by the patient.

Medication

Antibiotic, antiprotozoal, antiviral, or antifungal agents are used, depending on the cause of infection.

Antibiotics

Therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.


Penicillin G benzathine (Bicillin L-A, Permapen)

Interferes with synthesis of cell wall mucopeptides during active multiplication, which results in bactericidal activity.

Adult

Syphilis <1 year: 2.4 million U IM once in 2 injection sites
Syphilis >1 year: 2.4 million U IM in 2 injection sites qwk for 3 doses

Pediatric

Syphilis <1 year: 50,000 U/kg IM once; not to exceed 2.4 million U
Syphilis >1 year: 50,000 U/kg IM qwk for 3 doses; not to exceed 2.4 million U

Probenecid can increase penicillin effectiveness by decreasing clearance; coadministration with tetracyclines can decrease effectiveness

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired renal function; seizures may occur at high doses

Interferons

Naturally produced proteins with antiviral, antitumor, and immunomodulatory actions. Used for treating hepatitis B and hepatitis C.


Interferon alfa-2b (Intron A)

Indicated for hepatitis B. Protein product manufactured by recombinant DNA technology. Mechanism of antitumor activity not clearly understood; however, direct antiproliferative effects against malignant cells and modulation of host immune response may play important roles.

Adult

5 million U/d IM/SC or 10 million U 3 times per wk for 16 wk; reduce dose by 50% if severe reactions occur or temporarily discontinue therapy until symptoms from adverse reactions improve

Pediatric

Not established

Potential risk of renal failure when administered concurrently with IL-2; theophylline may increase toxicity by reducing clearance; cimetidine may increase antitumor effects; zidovudine and vinblastine may increase toxicity

Documented hypersensitivity to drug, mouse immunoglobulin (IgG), egg protein, or neomycin; autoimmune hepatitis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Depression and suicidal ideation may occur; infrequently, severe or fatal GI hemorrhage reported; prior to initiation of therapy, perform tests to quantitate peripheral blood hemoglobin, platelets, granulocytes, hairy cells, and bone marrow hairy cells; monitor periodically (eg, monthly) during treatment to determine response to treatment; if patient does not respond within 6 mo, discontinue treatment; if response occurs, continue treatment until no further improvement observed; not known whether continued treatment after that time is beneficial

Anthelmintics

Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.


Praziquantel (Biltricide)

Increases cell membrane permeability in susceptible worms, resulting in loss of intracellular calcium, massive contractions, and paralysis of musculature. In addition, produces vacuolization and disintegration of schistosome tegument. This is followed by attachment of phagocytes to parasite and death. Tabs should be swallowed whole with some liquid during meals. Keeping tabs in mouth may reveal bitter taste, which can produce nausea or vomiting.

Adult

Schistosomiasis: 20 mg/kg PO tid q4-6h
Clonorchiasis and opisthorchiasis: 25 mg/kg PO q4-6h
Hymenolepis: 25 mg/kg PO once
Intestinal infection with Taenia solium, Taenia saginata, Dipylidium caninum, or Diphyllobothrium species: 10-20 mg/kg PO once
Cysticercosis: 50 mg/kg/d PO divided tid for 14 d
Infection with Schistosoma haematobium or Schistosoma mansoni: 40 mg/kg/d PO divided bid once
Infection with Schistosoma japonicum or Schistosoma mekongi: 60 mg/kg/d PO divided tid once

Pediatric

<4 years: Not established
>4 years: Administer as in adults

Hydantoins may reduce serum concentrations, possibly leading to treatment failures

Documented hypersensitivity; ocular cysticercosis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Destruction of parasite within eyes can cause irreparable lesions (ocular cysticercosis should not be treated with praziquantel); caution while driving or performing other tasks requiring alertness on the day of and following treatment; minimal increases in liver enzymes reported; when schistosomiasis or fluke infection associated with cerebral cysticercosis, hospitalize patient for duration of treatment


Diethylcarbamazine citrate (Hetrazan)

For parasitic infections. Synthetic organic compound highly specific for several common parasites. Does not contain toxic metallic elements. Not recommended as DOC because of more severe adverse effects. Recommended if therapy with mebendazole fails or is not available.

Adult

3-4 mg/kg/d PO single dose for 4 wk

Pediatric

<2 years: Not recommended
>2 years: Administer as in adults

Documented hypersensitivity; children <2 y

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Start at low dose (25 mg/d) and progressively increase dose to avoid adverse reactions due to parasite lysis


Sodium antimony gluconate (Pentostam)

DOC for the treatment of leishmaniasis in United States. May be administered IV or IM. Intravenous use is preferred because large volumes are required. Available at 100 mg/mL. Dilute each mL in 10 mL of 5% dextrose water and administer over 15 min to prevent thrombophlebitis.

Adult

20 mg/kg/d IV (preferred) or IM
Cutaneous disease: Treat for 20 d
Mucocutaneous and visceral disease: Treat for 28 d

Pediatric

<20 kg: Increased dosing may be required to achieve efficacious serum levels; in United States, CDC must approve dose increase
>20 kg: Administer as in adults

None reported; patients should avoid taking drugs with similar toxicities and adverse effects, including those that are hepatotoxic or cause QT prolongation

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause myalgias and arthralgias (50%) and GI symptoms (eg, nausea, vomiting, anorexia, abdominal pain); hepatotoxicity and hematologic changes, including decreased WBC, hemoglobin, and platelet counts, can also occur in addition to cardiac dysrhythmias


Chloroquine phosphate (Aralen phosphate)

Inhibits growth by concentrating within acid vesicles of parasite, which increases internal pH of organism. Also inhibits hemoglobin utilization and metabolism of parasite.

Adult

600 mg PO on day 1, then 300 mg 6 h later, followed by 300 mg on days 2 and 3
Alternatively, 160-200 mg IM, repeat in 6 h prn; not to exceed 800 mg in first 24 h (change to PO dosing as soon as possible and continue for 3 d until 1.5 g is administered)

Pediatric

10 mg/kg PO on day 1, then 5 mg/kg 6 h later, followed by 5 mg/kg on days 2 and 3
Alternatively, 5 mg/kg IM, repeat in 6 h
Weight-based dosing: 10 mg base/kg PO (not to exceed 600 mg), then 5 mg base/kg PO (not to exceed 300 mg) at 6 h, 24 h, and 48 h to a total of 25 mg/kg

Cimetidine may increase serum levels (possibly other 4-aminoquinolones); magnesium trisilicate may decrease absorption of 4-aminoquinolones

Documented hypersensitivity; psoriasis, retinal and visual-field changes attributable to 4-aminoquinolones

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic disease, G-6-PD deficiency, psoriasis, and porphyria; not recommended for long-term use in children; perform periodic ophthalmologic examinations; test for muscle weakness; retinopathy, tinnitus, nerve deafness, skin eruption, headache, anorexia, nausea, vomiting, and diarrhea may occur

Antiviral agents

These agents are nucleoside analogs that inhibit viral replication.


Entecavir (Baraclude)

Guanosine nucleoside analogue with activity against HBV polymerase. Competes with natural substrate deoxyguanosine triphosphate to inhibit HBV polymerase activity (ie, reverse transcriptase). Less effective for lamivudine-refractory HBV infection. Indicated for treatment of chronic hepatitis B infection. Available as tab and oral solution (0.05 mg/mL; 0.5 mg = 10 mL).

Adult

Treatment for nucleoside naive: 0.5 mg PO qd 2 h ac or 2 h pc
CrCl 30-49 mL/min: 0.25 mg PO qd or 0.5 mg q48h
CrCl 10-29 mL/min: 0.15 mg PO qd or 0.5 mg q72h
CrCl <10 mL/min: 0.05 mg PO qd or 0.5 mg qwk

Receiving lamivudine or lamivudine resistance: 1 mg PO qd 2 h ac or 2 h pc
CrCl 30-49 mL/min: 0.5 mg PO qd or 1 mg q48h
CrCl 10-29 mL/min: 0.3 mg PO qd or 1 mg q72h
CrCl <10 mL/min: 0.1 mg PO qd or 1 mg qwk

Pediatric

<16 years: Not established
>16 years: Administer as in adults

Not a substrate, inhibitor, or inducer of cytochrome P450; coadministration with drugs that reduce renal function (eg, aminoglycosides, cidofovir, cyclosporine) or that compete for active tubular secretion (eg, probenecid, salicylates) may increase serum concentration of either entecavir or coadministered drug

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Reduce dose with renal impairment; if on hemodialysis, administer afterwards; common adverse effects include headache, tiredness, dizziness, and nausea; may elevate liver enzyme levels; may cause lactic acidosis; severe acute exacerbations of hepatitis B may occur in patients who discontinue antihepatitis B therapy


Lamivudine (Epivir-HBV)

Nucleoside analogue approved by the FDA for chronic hepatitis B treatment. Now considered first-line therapy, eclipsing interferon. Inhibits hepatitis B viral DNA polymerase. Use should be considered in patients with ongoing hepatitis B viral replication, elevated aminotransferase activity, and histologic evidence of liver injury. Consider for cases that failed, are unlikely to respond to interferon, or patients who cannot tolerate interferon. Discontinue lamivudine only when repeated assays demonstrated HBeAg loss or seroconversion to HBeAb. Emergence of resistance is the major drawback of nucleoside analogue monotherapy. Proper management of viral breakthrough in patients treated with lamivudine is not yet defined. Continuation of lamivudine appears to be warranted in most cases because resistant strains of HBV seem to be attenuated and are associated with only mild liver injury.
Note that the available dosage forms differ between Epivir and Epivir-HBV (formula specific for hepatitis B virus). Epivir-HVB is available as a 100 mg tab or oral solution 5 mg/mL, whereas Epivir contains 150 mg/tab or 10 mg/mL in oral solution.

Adult

100 mg PO qd

Pediatric

<2 years: Not established
2-17 years: 3 mg/kg/d PO qd; not to exceed 100 mg/d
>17 years: Administer as in adults

Trimethoprim/sulfamethoxazole increases bioavailability of lamivudine; lamivudine increases concentration of zidovudine when administered concurrently

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in renal impairment; caution in history of pancreatitis

More on Glomerulonephritis, Nonstreptococcal Associated With Infection

Overview: Glomerulonephritis, Nonstreptococcal Associated With Infection
Differential Diagnoses & Workup: Glomerulonephritis, Nonstreptococcal Associated With Infection
Treatment & Medication: Glomerulonephritis, Nonstreptococcal Associated With Infection
Follow-up: Glomerulonephritis, Nonstreptococcal Associated With Infection
References
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References

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  2. Atta MG, Gallant JE, Rahman MH, et al. Antiretroviral therapy in the treatment of HIV-associated nephropathy. Nephrol Dial Transplant. Oct 2006;21(10):2809-13. [Medline].

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  4. Chadban SJ, Atkins RC. Glomerulonephritis. Lancet. May 21-27 2005;365(9473):1797-806. [Medline].

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  8. Kamar N, Izopet J, Alric L, et al. Hepatitis C virus-related kidney disease: an overview. Clin Nephrol. Mar 2008;69(3):149-60. [Medline].

  9. Lu TC, Ross M. HIV-associated nephropathy: a brief review. Mt Sinai J Med. May 2005;72(3):193-9. [Medline].

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Further Reading

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Keywords

glomerular diseases associated with infection, glomerular disease, infection-related glomerulonephritis, GN, postinfectious glomerulonephritis, PIGN, bacterial infection, viral infection, protozoal infection, helminth infection, bacterial endocarditis, shunt nephritis, visceral abscesses, syphilis, hepatitis B, hepatitis C, human immunodeficiency virus, HIV, cytomegalovirus, CMV, parvovirus B19, Hantavirus, malaria, schistosomiasis, leishmaniasis, filariasis, hydatid disease, toxoplasmosis, aspergillosis

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Contributor Information and Disclosures

Author

James W Lohr, MD, Fellowship Program Director, Professor, Department of Internal Medicine, Division of Nephrology, State University of New York at Buffalo
James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, and Central Society for Clinical Research
Disclosure: Nothing to disclose.

Coauthor(s)

Quresh T Khairullah, MBBS, Consulting Staff, Department of Medicine, Division of Nephrology, St John's Hospital and Medical Center
Quresh T Khairullah, MBBS is a member of the following medical societies: American College of Physicians, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

Medical Editor

Frank C Brosius III, MD, Nephrology Program Director, Department of Internal Medicine, Division of Nephrology, Professor of Internal Medicine and Physiology, University of Michigan School of Medicine
Frank C Brosius III, MD is a member of the following medical societies: Alpha Omega Alpha, American Diabetes Association, American Society of Nephrology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ajay K Singh, MB, MRCP, MBA, Associate Professor of Medicine, Director of Dialysis, Department of Medicine, Harvard Medical School; Clinical Chief of Renal Division, Brigham and Women's Hospital
Disclosure: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Roche Honoraria Consulting

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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