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Area of Science:

  • Nephrology
  • Immunology
  • Pharmacology

Background:

  • Glucocorticoids (GCs) are primary treatments for glomerular diseases due to potent anti-inflammatory effects.
  • GC toxicities necessitate reduced cumulative exposure and exploration of alternative strategies.
  • Review synthesizes evidence on GC-sparing approaches in major glomerular diseases.

Purpose of the Study:

  • To evaluate the efficacy and safety of GC-sparing strategies in glomerular diseases.
  • To identify optimal reduced-GC regimens and novel therapeutic integrations.
  • To inform future clinical practice regarding GC use in nephrology.

Main Methods:

  • Systematic review of randomized controlled trials and key noncontrolled studies.
  • Analysis of GC-sparing strategies in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), lupus nephritis (LN), minimal change disease (MCD), and IgA nephropathy (IgAN).
  • Evaluation of evidence from trials like PEXIVAS and LoVAS.

Main Results:

  • Reduced-dose GC regimens in AAV maintain efficacy and lower infection risk.
  • In LN, lower-dose GCs combined with targeted agents (belimumab, calcineurin inhibitors, obinutuzumab) facilitate faster tapering.
  • Combination therapies with calcineurin inhibitors or mycophenolate achieve remission with less steroid exposure in MCD; IgAN practice shifts away from GCs.
  • GCs are increasingly used for early, time-limited induction in select glomerulopathies.

Conclusions:

  • GCs remain essential for induction in some inflammatory glomerulopathies but their role is narrowing.
  • GC-sparing strategies are effective and reduce toxicity in various glomerular diseases.
  • Further research is needed on IV methylprednisolone for rapid presentations and even lower-dose GC regimens.