Management of minimal lesion glomerulonephritis: Evidence-based recommendations

Abstract

Management of minimal lesion glomerulonephritis: Evidenceinvestigators include staining with IgM, and there may based recommendations. The treatment of idiopathic minimal be a spectrum of disease between minimal lesion and lesion disease in children has been extensively studied in ran-IgM mesangial proliferative glomerulonephritis. Indeed, domized controlled trials, however, there is less information this is a potential cause of confusion because some studavailable for adults. This article summarizes evidence-based ies allow mesangial proliferation and/or staining with recommendations for management. The first attack should be treated with prednisone or prednisolone at 60 mg/m 2 per day IgM as a variant of minimal lesion, whereas others do (up to a maximum of 80 mg/day) for four to six weeks, followed not. Although deposition of IgM does not appear to by 40 mg/m 2 of prednisone every other day for another four change prognosis, mesangial hypercellularity is associto six weeks (grade A). Relapse should be treated with 60 mg/ ated with late nonresponse [5]. Others have not found an m 2 /day of prednisone (up to 80 mg/day) only until the urine association between histology and postbiopsy course [6]. becomes protein free for three days, and then an alternate day regimen of 40 mg/m 2 should be used for another month (grade A). Patients with frequently relapsing disease will have a sig-Methods nificant reduction in relapse frequency after eight weeks of an The evidence used in compiling these recommendaalkylating agent (grade A). Less rigorous studies have sugtions was obtained from published trials found in a MEDgested benefit with long-term, alternate-day corticosteroid (grade D) or the antihelminthic agent levamisole (grade D). LINE search of the English language literature. Second-For patients with steroid-dependent disease, an 8-or 12-week ary references from the bibliography of the initial studies course with cyclophosphamide can induce remission (grade were also perused, as were personal files. Recommenda-D). In true steroid-resistant disease, observational studies have tions were graded from A to D, based on the level of suggested that a course of cyclosporine may sometimes induce evidence of the supporting studies. remission or restore steroid responsiveness (grade D). Large retrospective studies in adults suggest that therapeutic response is slower than in children, but adults experience fewer relapses and more prolonged remission.

Adult-Onset Minimal Change Disease among Taiwanese

“…Long-term corticosteroid tapering regimen for children with MCD was safer and more preferable than intermittent and short-course regimens to decrease the relapsing rate, maintain the longer remission time, and avoid the corticosteroid toxicity [21][22][23]. Recently, evidence-based recommendations for the management of children with MCD was formed [21], which suggested that the first attack should be treated with prednisolone 60 mg/m 2 per day for 4-6 weeks, and then 40 mg/ m 2 every other day for further 4-6 weeks; and patients with frequently relapsing disease will have a significant reduction in relapse frequency after 8 weeks of alkylating agent. But few randomized controlled studies have addressed the adequate treatment modality for adult-onset MCD [21].…”

“…The intensity of initial therapy for MCD appears to alter the clinical course, determinate the subsequent relapse, and perhaps also affect the chance of becoming a frequent relapser [6,21]. Long-term corticosteroid tapering regimen for children with MCD was safer and more preferable than intermittent and short-course regimens to decrease the relapsing rate, maintain the longer remission time, and avoid the corticosteroid toxicity [21][22][23].…”

“…Recently, evidence-based recommendations for the management of children with MCD was formed [21], which suggested that the first attack should be treated with prednisolone 60 mg/m 2 per day for 4-6 weeks, and then 40 mg/ m 2 every other day for further 4-6 weeks; and patients with frequently relapsing disease will have a significant reduction in relapse frequency after 8 weeks of alkylating agent. But few randomized controlled studies have addressed the adequate treatment modality for adult-onset MCD [21]. The treatment regimens for adult-onset MCD are still diverse and inconclusive, although most studies used the high-dose corticosteroid as the first-line initial treatment [21].…”

Rituximab in Steroid-Dependent or Frequently Relapsing Idiopathic Nephrotic Syndrome

“…4,5 However, 60%-70% of patients relapse after steroid tapering or withdrawal, and most require repeat courses of prednisone to achieve remission of recurrent episodes and/or the addition of other immunosuppressive medications, such as calcineurin inhibitors, mycophenolate mofetil, or alkylating agents, to reduce the number of relapses and prevent major side effects of steroid treatment. 6 According to their relapse rate, these patients are classically labeled as "steroid-dependent" or "frequently relapsing". In these patients, serious adverse effects of treatment associate with complications of relapsing episodes of heavy proteinuria.…”

Recent Update in The Management of Childhood Nephrotic Syndrome

“…The increase in the initial steroid dose acknowledges the evidence that the relapse rate is reduced with increased duration of initial therapy 19 . Now the intial episode is treated with prednisolone 60 mg/m 2 /day in 2-3 divided doses for 6 weeks followed by 40 mg/m 2 on alternate days as a single morning dose for 6 more weeks, after which it is discontinued 3,15 .…”