Guide to the practice of glomerulonephritis: implications an

Glomerulonephritis is the most common kidney disease in our country, and it is significant in practice in China to practice KDIGO glomerulonephritis therapy guidelines and norms. But in the KDIGO guidelines recommend treatment, except with lupus nephritis, the treatment of IgA nephropathy glomerular diseases such as some research evidence from China, most other evidence from clinical studies abroad, therefore, we should be scientific, objective view of the first edition KDIGO glomerular disease treatment guidelines.

KDIGO kidney glomerulonephritis therapy guide

Child nephrotic syndrome

Children, regardless of incipient or recurrence hormone sensitive nephrotic syndrome (SSNS) are the preferred glucocorticoid [60 mg/m2 or 2 mg/(kg · d)], course of treatment for at least 12 weeks.

Children with repeated recurrence or steroid-dependent SSNS, recommend alkylating agent (cyclophosphamide and benzyl butyrate nitrogen mustard), levamisole and calcineurin inhibitors (ring spore element A and tacrolimus) as the hormone replacement drugs; Suggest that oral cyclophosphamide (2 mg/(kg · d)] 8 ~ 12 weeks (maximum cumulative dose of 168 mg/kg), ring spore, A starting dose (4 ~ 5) mg/(kg · d) (two times) or tacrolimus starting dose of 0.1 mg/(kg · d) (two times), is not recommended as hormone replacement drugs azathioprine.

• for children's hormone-resistant nephrotic syndrome (SRNS), the recommendation of calcium phosphatase inhibitors as initial treatment is recommended for at least six months. The recommended combination of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor antagonists (ARB).

Kidney disease of minor lesions in adults

Small lesions, for adult kidney disease, recommend glucocorticoid treatment, suggest the daily meal take 1 mg/(kg · d) (maximum dose of 80 mg) a day or 2 mg/kg (maximum dose of 120 mg), starting dose hormone treatment is not more than 16 weeks.

Tiny lesions, for repeated recurrence or hormone dependent adult kidney disease, suggest that oral cyclophosphamide [(2 -) 2.5 mg/(kg · d)] 8 weeks or calcineurin inhibitor [A ring spore element (3 ~ 5) mg/(kg · d) or tacrolimus (0.05 ~ 0.1) mg/(kg · d), two oral].

Adult idiopathic focal glomerular sclerosis (FSGS)

• for adult FSGS, it is recommended that you only use hormones and immunosuppressants in the presence of nephrotic syndrome, and recommend adequate levels of the hormone for 4-16 weeks. For hormone-resistant FSGS, the recommended cyclosporin A (3 ~ 5) mg/(kg d) for 4 to 6 months.

Membranous nephropathy

• treatment of glucocorticoid and immunosuppressant is recommended when patients with membranous nephropathy are characterized by nephrotic syndrome. Initial treatment is recommended every month alternate vein - oral corticosteroids and oral alkylating agent (suggest cyclophosphamide), or A ring spore element or tacrolimus therapy for at least six months; The use of glucocorticoids alone is not recommended as initial treatment.

• for patients with recurrent membranous nephropathy, it is recommended to use the original treatment.

IgA nephropathy

• the guidelines, first, assess the risk factors for progressive IgA nephropathy; Secondly, the treatment is mainly focused on proteinuria and decompression. When the urine protein > 1 g/d, the recommended use of ACEI or ARB treatment is recommended, and the target blood pressure is < 130/80 mmHg; If the urine protein is (0.5 ~ 1) g/d [child is in (0.5 ~ 1) g/(d · 1.73 m2)], the recommended use of ACEI or ARB treatment is recommended, and the target blood pressure is < 125/75 mmHg; When ACEI or ARB are treated for 3-6 months and the proteinuria continues > 1.0 g/d, the patient should receive 6 months of glucocorticoid therapy.

• the guidelines also highlight the treatment of special type IgA nephropathy: a minor disease, IgA nephropathy, a treatment regimen with a small lesion of the kidney disease; The new moon was IgA kidney disease, and the treatment was similar to the anti-neutrophils' cytoplasmic antibody (ANCA).

Lupus nephritis

• the KDIGO lupus nephritis (LN) treatment guidelines emphasize that a diagnosis of renal biopsy is required, and that the patient's histological change is the basis of the choice of treatment.

• Ⅰ and Ⅱ LN can be clinical manifestation to determine treatment plan according to the kidney.

• in the case of proliferative natural log, emphasis is placed on stage treatment, which is the initial treatment and maintenance of the treatment. Ⅲ and Ⅳ LN recommend corticosteroids combined cyclophosphamide or primary treatment for McCaw phenol ester (MMF), to maintain ease azathioprine treatment recommended [(1.5 ~ 2.5) mg/(kg · d)] or MMF [(1 ~ 2) g/d, taking] treatment, oral small doses of corticosteroids at the same time.

Type, simple Ⅴ LN expression is kidney disease levels of albuminuria, suggested that hormone with immunosuppressant therapy.

• the guidelines recommend that all natural log patients should be treated with hydroxychloroquine (6 ~ 6.5 mg/kg). For recurrent patients, it is recommended to resume initial treatment or maintenance. The refractory natural log can be considered for repetitive kidney biopsy. Patients with phospholipid syndrome should be treated with anticoagulation.

Chinese clinical research has contributed to the KDIGO guide's contributions and problems

At present our country on the diagnosis and treatment of glomerulonephritis have greatly improved, has completed the prevalence of chronic kidney disease (CKD) and end-stage renal disease (ESRD) causes the regional survey, the results showed that glomerulonephritis is still the most common cause of ESRD in our country, which accounts for about 57%.

Chinese research has been introduced to the KDIGO guidea

In the KDIGO glomerulonephritis guide, some Chinese studies have been cited.

It for 7 of phenol ester, for example, treating severe LN (nanjing general hospital of nanjing military region), multiple targets immune to new treatments for type Ⅴ + Ⅳ LN (nanjing general hospital of nanjing military region), tacrolimus and hormone treatment of adult hormone dependent small lesions and cyclophosphamide hormone resistant nephrotic syndrome (zhejiang university hospital), hormone combined ACEI treatment of IgA nephropathy (the first hospital of Peking University), and other clinical studies were guidelines referenced.

But at present the studies are still exists defects such as small sample, the multicenter, while other glomerulonephritis (such as membranous nephropathy, FSGS) of the related research for lack of convincing or not in international academic journals, and thus has not been KDIGO guidelines for reference.

There are still insufficient studies of glomerulonephritis in China

Although China has made significant progress in the study of glomerulonephritis, the relevant randomized controlled study (RCT) remains too small.

According to statistics, since 2000, China in the international register of RCT studies of glomerulonephritis only 18, eventually RCT less than 20 papers published (excluding Hong Kong, China and Taiwan). There are only 11 Chinese studies included in the KDIGO glomerulonephritis guidelines, and the real RCT study is only five. This is not proportional to the high incidence of glomerulonephritis in our country and the number of cases.

Therefore, domestic experts urged must strengthen clinical trials in China, actively carry out prospective, multicenter, randomized, controlled clinical studies, hope in the future for the guide to update provides strong evidence of evidence-based medicine from China really solve the problem of Chinese standardization treatment of glomerulonephritis.

The good news is that a number of large, forward-looking and randomized controlled clinical studies are being carried out at home. , for example, the general hospital of nanjing military region cruzado jm academician of multiple targets induction therapy LN prospective randomized multicenter study, will further verify the efficacy of multiple targets for therapy in patients with LN, LN and the different types of classification, in addition, also organized a hormone combination for McCaw phenolic resin in the treatment of hyperplastic IgA nephropathy multicenter prospectie study, tacrolimus hormone treatment of adult type resistance FSGS prospective multicenter study; Wang haiyan, a professor at Peking University's first hospital, has launched an international multi-center TESTING study to assess the efficacy and safety of glucocorticoids in patients with high-risk IgA nephropathy.

The guidelines are challenged in practice in China

Due to domestic treatment of glomerulonephritis, there is no unified standard, therefore, KDIGO glomerulonephritis guide to regulating the treatment of glomerulonephritis in China will undoubtedly play a positive role in promoting, but due to the guidelines of clinical trial evidence cited in the vast majority of the study from abroad, non-chinese ethnicity, and the clinical phenotype of diseases and treatment response of racial differences, therefore, KDIGO guidelines recommended or suggested treatments are suitable for Chinese people also need further verification.

Chinese experts consistently believe that the dose and treatment of hormone therapy for nephrotic syndrome should be different from western countries, but there is not enough evidence of evidence-based medicine. At the same time, the KDIGO guideline referenced most clinical trials abroad limited by the number of observed objects, often observe objects of the disease as a whole, such as in patients with chronic kidney disease (CKD) is hard to press the cause analysis, LN and IgA nephropathy is difficult to achieve classification treatment of observation. In addition, with the development of science and technology, all kinds of used for clinical treatment of curative effect evaluation of new drugs, all need large sample, prospective, multicenter, randomized controlled observation.

At this stage, therefore, USES the KDIGO guidelines glomerulonephritis clinical practice has important clinical significance in our country, but how to more effective treatments for the various chronic glomerulonephritis, eventually must be continuous development of our country high-level evidence-based medical evidence to explore and answer.