Glomerulonephritis — 1974
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Glomerulonephritis presents clinically in only a few ways, and similar patients have differing underlying pathogenesis and renal histology. Renal biopsy therefore plays an important part in diagnosis.
Patients with a nephrotic syndrome and normal glomeruli (“minimal change” lesion) respond reliably to short (six week) courses of corticosteroids; prolonged treatment is unnecessary and may be dangerous.
Half such patients will have only one nephrotic episode, but the remainder relapse at least once, and usually repeatedly. If these relapsing patients cannot be controlled by corticosteroids without unacceptable toxicity, then treatment with a short eight week course of cyclosphamide is justified. This will induce remission lasting an average of three years in both adults and children.
Patients with other forms of primary glomerulonephritis associated with glomerular scarring, chronic proteinuria and sometimes declining renal function, can only be harmed by corticosteroids or cytotoxic agents alone or in combination. Although complicated regimes involving the use of anticoagulant and antiplatelet drugs are under trial at the moment, the most important aspect of management is the early detection and effective treatment of their associated hypertension.
We now know that patients with chronic glomerulonephritis probably suffer from an inability to clear antigens effectively and hence form small, circulating antigen-antibody complexes which localise in the kidney because of its high bloodflow and high capillary permeability. This inefficiency in clearing antigen represents a relative immunodeficiency. It may be inherited, acquired by circumstances such a protein-energy malnutrition, or perhaps by acquisition of partial tolerance to an antigen with time. Immunosuppression could at least theoretically make this situation worse.
The only group of patient in whom immunosuppression for long periods seems to have a place at the moment, is the treatment of nephritis in systemic lupus erythematosus and polyarteritis nodosa. Even here, long term benefit is not yet proven and the régimes produces obvious morbidity and mortality.
The clinical importance of glomerulonephritis has been increased now that terminal renal failure can be treated by either regular dialysis or by transplantation. About two thirds or even three quarters of patients submitted to these procedures have as their primary disease one form of glomerulonephritis or another (Gurlandet al., 1973). Despite the considerable success in treating a previously fatal condition, misery and death still afflict a proportion of patients: the chronic stress of home dialysis is such that not all patients can cope, and one quarter of patients and one half of grafts are dead within two to three years following cadaver transplantation (Tenth report of the International Transplant Registry, 1972). Apart from this human aspect, the cost of these procedures in skilled personnel, time and hard cash is such that we must consider prevention or palliation of glomerular and other chronic renal diseases our goal, and regardall dialysis and transplantation as failures of preventitive medicine, rather than advances in medical technology.
KeywordsSystemic Lupus Erythematosus Nephritis Glomerulonephritis Lupus Nephritis IRISH Journal
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