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The treatment of glomerulonephritis in children
1Evelina Children's Unit, Guy's Hospital, London, UK.
Insights
Newer treatments like pulsed methylprednisolone and plasma exchange significantly improve outcomes for childhood glomerulonephritis (GN), especially crescentic GN. Early intervention is crucial for better renal function recovery and reduced mortality.
Area of Science:
- Pediatric Nephrology
- Immunology
- Internal Medicine
Background:
- Glomerulonephritis (GN) encompasses various kidney diseases affecting children.
- Treatment effectiveness varies significantly based on GN subtype and disease progression.
Purpose of the Study:
- To review and compare the efficacy of different glomerulonephritis treatments in children.
- To evaluate outcomes against the natural history of untreated glomerulonephritis.
Main Methods:
- Comparative review of existing treatment modalities for childhood GN.
- Analysis of data on oral corticosteroids, immunosuppressants, anticoagulants, pulsed methylprednisolone, and plasma exchange.
- Comparison with natural history data of untreated glomerulonephritis.
Main Results:
- Poststreptococcal GN and Schönlein-Henoch purpura nephritis generally require no specific treatment unless crescents are present.
- Mesangiocapillary GN progression may be slowed or reversed with long-term alternate-day steroids.
- Plasma exchange can restore renal function in antibody-mediated GN if treatment is initiated early.
- For rapidly progressive (extracapillary) GN with crescents, pulsed methylprednisolone and plasma exchange reduce mortality from 85-90% to approximately 25%.
Conclusions:
- Children with crescentic GN and declining function should receive initial pulsed methylprednisolone therapy.
- Plasma exchange is recommended for non-responders or those deteriorating after initial pulse therapy.
- Early treatment initiation is critical for achieving favorable outcomes in childhood glomerulonephritis.
Abstract:
The results of treatment of glomerulonephritis (GN) in childhood with oral corticosteroids, immunosuppressive drugs, anticoagulants and the newer regimens of pulsed, high-dose intravenous methylprednisolone and plasma exchange are reviewed and compared with the natural history of the untreated condition. Poststreptococcal GN and the nephritis of Schönlein-Henoch purpura need no specific treatment unless extensive glomerular crescents are present. The progression of mesangiocapillary GN can probably be slowed or even reversed with long-term, alternate-day steroid therapy. As in adults, recovery of renal function in GN due to antibody to glomerular basement membrane can be achieved in some patients using plasma exchange, but only those in whom some renal function is still present when treatment is started. In rapidly progressive (extracapillary) GN with crescents, "traditional" therapy with oral steroids, immunosuppressive drugs and anticoagulants reduces renal mortality from 85%-90% to about 50%, while pulsed methylprednisolone and plasma exchange improve the outcome further, mortality falling to about 25%. It is recommended that children with crescentic GN and deteriorating function be treated initially with pulsed methylprednisolone, followed by plasma exchange in those who fail to respond or who deteriorate following temporary response to pulse therapy. Treatment must be given early in the course of the illness if good results are to be obtained.
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