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 9,479 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

We discuss here a new approach to the treatment of idiopathic membranous glomerulonephritis (IMGN). Steroids and cytotoxic drugs have been used during the last years for the treatment of this disease, but the results are controversial. We develop here the hypothesis that the pathogenesis of IMGN is a relative incompetence of the immune system in clearing foreign antigens. Therefore, most patients should benefit from immune stimulation in the direction of a greater and more avid immune response.
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PMID:Immune stimulation. A new approach in the treatment of glomerulonephritis. 322 56

Membranous nephropathy is the most frequent histological category among black children with nephrotic syndrome. In this study 31 African children with this condition are described. There were more boys than girls and the peak age was four to 11 years. The incidence of this histological category and clinical outcome in the African children were similar to these features in adults with membranous nephropathy. During a follow-up period of up to six years there was spontaneous remission in a third of patients, persistent proteinuria in just over a third (37.5%) and persistent relapse in under a third (29.2%). Hypertension occurred more frequently (19.3%) and spontaneous remission less often (33.3%) than in children with membranous nephropathy elsewhere. Hypertension, the lower remission rate and persistence of proteinuria during the course of the disease were similar to the disease seen in adults. Renal failure was not encountered in any patients. Steroids were of little value in the treatment of these children. Five children (16.2%) had associated infections. HBsAg was present in three of six children tested.
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PMID:Extramembranous nephropathy in black South African children. 619 44

Primary chronic glomerulonephritis may emerge clinically as acute nephritis, the nephrotic syndrome as well as asymptomatic hematuria and proteinuria. Therapeutic consequences still depend on the morphological diagnosis. In cases of minor proteinuria [< 3,5 g/24 h] immunosuppressive therapy is not superior to symptomatic therapy. In patients with nephrotic syndrome immunosuppressive therapy depends on the morphological diagnosis. Glucocorticoids are the therapy of choice in minimal changes glomerulopathy and should be tried in focal segmental sclerosing glomerulonephritis. Steroids may be tried in pure mesangial as well as in IgA and IgM nephropathy. Especially Ponticelli claims significant therapeutic success in patients with membranous glomerulonephritis treated with Prednisolone and Chlorambucil. Failures and relapses may be treated with Cyclophosphamide, Chlorambucil or Cyclosporin A. Anticoagulants may be advantageous in the therapy of membranoproliferative glomerulonephritis.
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PMID:[Therapy of primary chronic glomerulonephritis]. 778 93

Because of the high rate of spontaneous remission, treatment of membranous nephropathy with prednisolone and chlorambucil is still controversial. The aim of this study was to give this therapy only to those patients at risk of developing renal insufficiency and to test the efficacy of a low-dose therapeutic regimen. Seventeen patients with more than 10 g protein excretion per day (mean 16.9) and/or a deterioration in renal function (mean serum creatinine, 162 mumol/l) were included. Serum total protein, serum lipids, proteinuria, serum creatinine, and blood pressure were measured, along with the diuretic and antihypertensive medication. The observation time before the start of treatment was 27 +/- 27 months. Steroids were given during months 1, 3, and 5 (methylprednisolone 3 x 500 mg intravenously) prednisolone 0.5 mg/kgBW daily per os for 1 week, then tapered by 0.1 mg/kg BW/week for 1 month). Chlorambucil was given during months 2, 4, and 6 at a dose of 0.12 mg/kgBW daily. At the end of treatment proteinuria had significantly decreased (mean of all patients, 7.8 +/- 1.4 g/d) in all patients. Six months after the end of treatment proteinuria was significantly lower than at baseline in 14 of 17 patients. Hypoproteinemia and hyperlipidemia had improved; diuretic and antihypertensive medication were reduced. Elevated serum creatinine decreased in 7 of 9 patients (pretreatment, 227 +/- 39 mumol/l; 6 months, 176 +/- 28 mumol/l). Nonresponders with respect to serum creatinine responded with respect to proteinuria. Regarding adverse effects, two patients complained of dyspepsia while taking steroids; during chlorambucil treatment two patients experienced nausea and lack of appetite, and one developed leukopenia (1600/microliters).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Low-dose prednisolone/chlorambucil therapy in patients with severe membranous glomerulonephritis. 804 74

Hepatitis B virus (HBV) infection is recognised as an important cause of nephrotic syndrome in endemic areas. This paper retrospectively examines the natural history and treatment of 70 patients with membranous glomerulonephritis and 1 with mesangiocapillary glomerulonephritis associated with HBV infection. Thirty-seven patients were in complete remission by the end of the study. The average duration of proteinuria in these patients was 30 months. The cumulative probability of remission was 64% at 4 years and 84% at 10 years. Three patients were still nephrotic after more than 90 months of follow-up and 2 others had reached end-stage renal failure. Remission occurred within 6 months of clearing the antigen (HBeAg) in the majority of cases. Steroids alone were given to 10 patients and 2 received steroids and cyclophosphamide, with no beneficial effect. Three patients received interferon-alpha 2b. One cleared the HBeAg from the circulation and had a significant fall in proteinuria, but defaulted from follow-up a month after completing treatment. One had a reduction of proteinuria but remained HBeAg positive. There was no change in the condition of the third. Although the majority of children eventually enter remission, there is a significant morbidity associated with the disease. Steroids and other immunosuppressive therapy are of no benefit. Interferon therapy may be useful, but has not been adequately assessed.
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PMID:The clinical course of hepatitis B virus-associated nephropathy. 814 8

We retrospectively studied 12 Japanese children (8 boys, 4 girls) with idiopathic membranous nephropathy (IMN), aged 2.9-15.8 (mean 7.7) years at onset. All patients were identified through either screening or a routine urinalysis; proteinuria was present in all, haematuria, which was macroscopic in 4, in 11. Three had nephrotic syndrome (NS) at or soon after onset. Stages on electron microscopy, performed in 10 patients, were I in 3, II in 5 and III in 2. Steroids alone or with cyclophosphamide were administered to 5 patients, including the 3 patients showing NS. Complete remission of proteinuria occurred in 8 patients 0.3-1.6 (mean 0.6) years after onset, and proteinuria did not recur. After a follow-up of 1.6-11.6 (mean 5.9) years, these 8 patients were in complete remission and the remaining 4 had only mild proteinuria; none had hypertension or impaired renal function. Thus, we infer that IMN in Japanese children may have a better course and outcome than IMN in non-Japanese children. Based on a comparative study of Japanese (previously reported cases added to ours) and non-Japanese (mostly Caucasian) children with IMN, this was confirmed; it is possible that steroid therapy in Japanese patients is more effective in inducing remission of NS and preserving renal function.
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PMID:Clinical course and outcome of idiopathic membranous nephropathy in Japanese children. 839 47

Eight patients with resistant and/or relapsing nephrotic syndrome or renal insufficiency were empirically treated with mycophenolate mofetil (MMF). The underlying glomerular diseases were membranous nephropathy (N = 3), minimal change disease (n = 2), focal segmental glomerulosclerosis (n = 1), and lupus nephritis (N = 2). Treatment with MMF 0.75 to 1.0 g twice daily, either as monotherapy or in combination with low-dose steroid treatment, resulted in substantial reductions in proteinuria or stabilization of serum creatinine. In relapsing patients following withdrawal from cyclosporin A, MMF achieved suppression of proteinuria equivalent to or better than that which occurred during cyclosporin A treatment. Steroids were successfully withdrawn in each of the non-lupus patients. MMF was well tolerated with no evidence of hematologic, hepatic, or other toxicity. These clinical anecdotes demonstrate the short-term clinical efficacy of MMF treatment. In addition, they suggest that MMF may have major steroid-sparing effects and might represent an alternative to cyclosporin A in appropriate patients.
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PMID:Successful mycophenolate mofetil treatment of glomerular disease. 946 13

Membranous nephropathy remains the most common cause of nephrotic syndrome in adults. The common variant is idiopathic membranous nephropathy with no evidence of any known precipitating factors. Membranous nephropathy also occurs as a secondary form in association with inflammatory or neoplastic diseases. Prognosis is mostly favorable as shown by the frequency of spontaneous remissions which averages 30%, although about one-third of patients progress to end-stage renal failure. Risk factors for a poor prognosis include severe proteinuria, hypertension, older age, male gender and impaired renal function. Therapy should include an ACE-Inhibitor and/or angiotensin-II receptor blocker to lower proteinuria (blood pressure < or =130/80 mmHg). The majority of patients should be observed for six months whilst receiving conservative treatment before deciding about an immunosuppressive approach. The debate over its management continues today. Steroids alone are ineffective. Evidence-based medicine supports the use of cyclosporine or the Ponticelli regimen (monthly cycling routine of chlorambucil or cyclophosphamide alternating with prednisone).
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PMID:[Membranous glomerulonephritis]. 1456 65

This series of articles on the management of glomerulonephritis (GN) has been prepared by a team of experts in the evidence-based format consistent with peer review of published data. Each author was asked to review the literature for his assigned histological type, with emphasis on therapy and limited to adult studies. The age limit was not considered for minimal change disease and focal segmental glomerulosclerosis, because of the high prevalence of these glomerulopathies in children. The particular treatment recommendations for each type of glomerular disease were graded by each author according to the amount of evidence provided in these reviewed studies. The first two articles concentrate on indications and techniques for kidney biopsy. Each subsequent article focuses on and describes the highest level of evidence supporting the recommendation for therapy in IgA nephropathy (Ig-GN), minimal change nephropathy (MCN) and focal segmental glomerulosclerosis (FSGS), membranous glomerulonephritis (MGN), lupus nephritis, ANCA-associated vasculitis, HCV-associated cryoglobulinaemia and renal involvement in paraproteinemic disorders. The article on IgA nephropathy emphasises the importance of carefully evaluating both clinical and histologic findings before settling on the treatment. The recent, renewed interest in steroids and many immunosuppressive agents is discussed in detail. Recommendations related to the patient's age are also provided. MCN and FSGS are treated together because these forms share similar evidence-based recommendations. For both of these diseases, in fact, the initial treatment approach in children should be prednisone or prednisolone for four to six weeks. The therapeutic response in adults is slower than in children, but adults experience fewer relapses and a more prolonged remission. There is also a discussion on treatment of relapse, frequent relapsing disease and true steroid-resistant disease as well as the role of new immunosuppressive agents. Membranous nephropathy is a frequent cause of nephrotic syndrome in adults and, in one third of these patients, leads to end-stage renal disease. However, the treatment of this form is as yet a matter of discussion. Based on extensive critical review of the literature, the following recommendations are put forward: (a) no treatment in the absence of nephrotic syndrome; (b) patients with heavy proteinuria should receive a 6-month treatment with i.v. methylprednisolone (MP) pulse therapy for three consecutive days followed by oral MP (0.4 mg/kg/day) (months 1, 3, 5) and chlorambucil or cyclophosphamide (months 2, 4, 6); (c) the dosage of chlorambucil or cyclophosphamide should be lowered in older patients; (d) cyclosporine is a second-choice treatment. The treatment of lupus nephritis depends on the histologic class. No specific treatment is usually necessary for class I and IIA. Oral steroids are indicated in patients with class IIb, proteinuria and active systemic disease. Steroids and azathioprine are the treatment of choice for patients with class III and IV, but cyclosporine can be an effective alternative therapy. Cyclophosphamide is more effective than azathioprine when severe acute renal involvement is present. The treatment of ANCA-associated vasculitis depends mainly on clinical presentation, oral prednisone + oral or i.v. cyclophosphamide are generally effective. In the most severe cases, the association of MP pulse therapy with cyclophosphamide is probably more effective. Plasma exchange is probably justified in unresponsive patients. Azathioprine should replace cyclophosphamide during the maintenance therapy. In HCV-associated mixed cryoglobulinemia the treatment also depends on the severity of renal involvement. The treatment for chronic HCV infection involves alpha interferon alone or preferably in combination with ribavirin. Aggressive therapy, including i.v. MP, plasmapheresis and cyclophosphamide is primarily reserved for patients with acute severe disease, as manifested by progressive renal failure, distal necroses requiring amputation, or advanced neuropathy. Uncontrolled studies suggest that this regimen can improve renal function. Renal involvement is a common problem in paraproteinemic disorders that include multiple myeloma, Waldentrom's macroglobulinaemia and monoclonal gammopathy. The most common renal diseases in this setting are cast nephropathy, primary amyloidosis cast nephropathy, primary amyloidosis, and light chain deposition disease that are related to the overproduction of monoclonal immunoglobulin light chains. The approach to therapy varies with the cause of the renal dysfunction. Patients with amyloidosis or light-chain deposition disease are generally treated with chemotherapy, but the most effective therapy for myeloma kidney is prevention by minimising the risk factors that promote light chain filtration and subsequent obstruction by cast formation within the tubules. Chemotherapy or stem cell or bone marrow transplantation to decrease filtered light chain load, prevent volume depletion and maintain high fluid intake to reduce light chain concentration within the tubular lumen are indicated in almost all the patients.
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PMID:[Instructions and implementations for percutaneous renal biopsy. Guidelines for the therapy of glomerular nephropaties]. 1466 2

Idiopathic membranous nephropathy (IMN) remains the most common histologic entity associated with adult-onset nephrotic syndrome. The therapy for IMN is challenging. Steroids and various other immunosuppressive agents have been tried in IMN; however, current agents have not altered the course of IMN, are nonspecific and can be very toxic. In native kidneys affected by IMN, rituximab, a monoclonal antibody against the B-cell surface antigen CD20, has been shown to reduce proteinuria and prevent disease progression. In this report, we describe a 39-year-old white male with end-stage renal disease secondary to IMN that, 4 months post living unrelated kidney transplant, developed recurrent IMN with 18 g/day of proteinuria. In addition to angiotensin converting enzyme inhibitor and statins, the patient was treated with 4 weekly doses of 375 mg/m2 of rituximab with significant reduction in proteinuria, a corresponding increase in serum albumin and improvement in hypercholesterolemia. At 3 years post-transplant, his kidney function remains stable with 0.5 g/day of proteinuria.
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PMID:Anti-CD20 monoclonal antibody (rituximab) for the treatment of recurrent idiopathic membranous nephropathy in a renal transplant patient. 1729 27


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