Empiric therapy for acute glomerulonephritis or RPGN
What is appropriate empiric therapy for patients with acute glomerulonephritis or RPGN?
Kidney biopsy should be performed expeditiously and appropriate laboratory studies should be sent when the patient presents. While waiting for these results, the initiation of steroid therapy—the mainstay inductive anti-inflammatory therapy for most acute inflammatory glomerular diseases—is reasonable. Toxicities from high-dose steroid therapy are minimal and manageable during this short “window” between patient presentation and obtaining diagnostic test results.
The initiation of cytotoxic or other immunosuppressive treatments, which consolidate treatment response to steroids, or plasma exchange, should wait until a definitive diagnosis is established. Analysis of clinical trial outcomes for some glomerular diseases suggests that benefit from cytotoxic drugs occurs well after disease onset, and most experts feel that the use of these agents can be delayed until diagnosis is established. Dosing for cyclophosphamide must be adjusted in the patient with altered kidney function to avoid leukopenia. The spectrum of agents used in modern protocols has expanded greatly to include biologics as well as additional classes of nonspecific immunosuppressive drugs, such as calcineurin inhibitors and mycophenolate.