Glomerulonephritis Associated with Nonstreptococcal Infection Treatment & Management

Updated: Mar 19, 2018
  • Author: James W Lohr, MD; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Treatment

Approach Considerations

In most cases, the treatment of postinfectious glomerulonephritis (PIGN) is based on treating the underlying infection. In certain instances, immunosuppressive agents such as corticosteroids may be employed to reduce glomerular inflammation. Inpatient care depends on the severity of infection, and the need for hospitalization depends on the clinical condition of the patient (eg, the patient may require dialytic support or IV fluids and antibiotics). If bacterial endocarditis or a shunt infection does not respond to antibiotics, then surgical intervention is indicated.

Oral antibiotics can be continued in an outpatient setting, with frequent monitoring of kidney function. Outpatient dialysis, if necessary, may need to be arranged.

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Medical Care

Bacterial

The majority of patients are infected with methicillin-resistant Staphylococcus aureus (MRSA) and antbiotics are the typical treatment for most cases. [4]

Treatment of shunt infections and visceral abscesses is usually is based on culture sensitivity results.

Viral

Chronic hepatitis B

Treatment is indicated if associated liver dysfunction is present. Current first-line agents are pegylated interferon alfa (PEG-IFN-a), entecavir (ETV), and tenofovir disoproxil fumarate (TDF). For complete discussion, see Hepatitis B.

Chronic hepatitis C

Guidelines for the treatment of patients with hepatitis C, including viral genotype–specific therapy and recommendations for patients with renal impairment, have been issued by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (ISDA) and are available at https://www.hcvguidelines.org/ Current recommendations vary for patients with an estimated glomerular filtration rate (eGFR) of >90 to >30 mL/min (ie, chronic kidney disease [CKD] stages 1-3) versus those with eGFR < 30 mL/min or end-stage renal disease [ESRD]). For more information, see Hepatitis C.

In addition to antiviral therapy, treatment may include B-cell depletion therapy with rituximab to prevent formation of immune complexes and cryoglobulins, or nonspecific immunosuppressive therapy targeting inflammatory cells to prevent the synthesis of immune complexes and treat cryoglobulin-associated vasculitis. [18]

HIV

Highly active antiretroviral therapy (HAART) is the standard of care for patients with HIV, with or without nephropathy. [19] 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 ESRD. Patients should also be started on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), as this may slow the progression of disease.

Syphilis

Nephropathy is usually observed in secondary syphilis because this phase is associated with high levels of immune complexes. If central nervous system or ocular involvement is not present, treatment is similar to primary syphilis (ie, a single intramuscular 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.

Other viral agents

Nephropathy associated with cytomegalovirus, parvovirus, and polyomavirus infections is observed in immunocompromised individuals and those who have undergone renal transplantation. Treatment is with specific antiviral agents (ie, ganciclovir for cytomegalovirus, cidofovir for polyomavirus [JC and BK virus]) and temporary withdrawal of immunosuppression therapy.

Parasitic

Malaria

Antimalarial drugs are the cornerstone of treatment of falciparum malaria. For more information, see Malaria.

Treatment of malaria-associated GN involves supportive measures such as hydroelectrolytic disturbances corrections, fluid replacement, and dialysis. [9]  Dialysis is required in 46-76% of cases, and complete renal function recovery is reported to occur in approximately 64% of cases in both Plasmodium falciparum and P vivax malaria.  Early initiation of dialysis has been associated with better outcomes. [8]  

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. Patients may benefit from either cyclosporine or cyclophosphamide, with remission reported in a third of cases. [9]

Leishmaniasis

Agents used in leishmaniasis treatment include antimony compounds (eg, sodium stibogluconate) and amphotericin B, pentamidine, and paromomycin. For more information, see Leishmaniasis. Diethylcarbamazepine and ivermectin are used for treating filariasis.

Fungal

For aspergillosis, treatment is based on the site of infection and usually includes amphotericin. For more information, see Aspergillosis>.

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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.

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