Fundamental concepts and immunosuppressive treatment in the various forms of glomerulonephritis

Immunosuppressive treatment in glomerulonephritis (GN) is still controversial. Most of the secondary forms of glomerulonephritis have the histologic features of one of the primary types of glomerulonephritis. Eight histologic expressions of primary glomerulonephritis can be distinguished and ordered in terms of severity of symptoms and prognosis: endocapillary GN, minimal change GN, mesangioproliferative GN, membranous GN, focal-sclerosing GN, membranoproliferative GN, focal-necrotizing GN, and rapidly progressive GN. Agreement exists only to the extent that immunosuppression is not required in endocapillary glomerulonephritis, although it is recommended in the other extreme of rapidly progressive GN. Primarily, an indication for immunosuppression is given by the severity of symptoms with a urinary protein excretion > 3.5 g per day and/or serum creatinine > 150 mumol per liter. As for anti-GBM, the type of glomerulonephritis is more important than the severity of symptoms in guiding therapy, whereas for IgA nephropathy it is controversial whether the prospective prognosis of even inexorably deteriorating renal function justifies immunosuppression. Renal biopsy is required to identify the type of glomerulonephritis so as to establish the specific immunosuppressive concept with different intensity and duration of treatment. Immunosuppression can reduce urinary protein excretion and improve deterioration of renal function; however, the proportion of patients responding varies with and depends on the different forms of GN.