Management of hematuria and proteinuria
B: Renal/urinary tract disease should be excluded in patients with microscopic hematuria (≥5 red blood cells/high magnification view). (Ⅲ)
B:Urine phase contrast microscopy under standard conditions is recommended to differentiate between glomerular-derived and non-glomerular-derived hematuria. (Ⅲ)
B: Patients with simple asymptomatic microscopic hematuria should be monitored for renal function and blood pressure at 6- to 12-month intervals. (Ⅲ)
B: In patients under 40 years of age with asymptomatic microscopic hematuria who lack clinical features of malignancy, a complete urologic examination is not required. (Ⅲ)
B: Patients with upright proteinuria have a good prognosis and do not require follow-up. (Ⅲ)
B: Patients with intermittent proteinuria alone have a good prognosis, but should be followed up 6 times a month until the protein disappears. (Ⅲ)
B: Patients with persistent simple proteinuria are at high risk of developing renal insufficiency and should be monitored continuously for blood pressure and renal function. (Ⅲ).
B: Patients with persistent urine protein ≥1g/ d have poor renal histology and prognosis and should undergo renal puncture biopsy. (Ⅲ)
B: Further renal endoscopy should be performed in patients with microscopic hematuria with proteinuria, especially in the presence of erythrocyte tubularity, hypertension and/or renal insufficiency. (Ⅲ)
B: Urologic pathology, including ultrasound, intravenous pyelogram and cystourethroscopy, should be performed in all patients with visual hematuria. (Ⅲ)
Management of glomerular disease General measures
B: Patients with renal disease with blood pressure ≥140/ 90 mmHg should be managed to slow the rate of deterioration of renal function. (Ⅱb)
B: For patients with blood creatinine < 600 μmol/ L and total urinary protein excretion rate ≥ 1 g/ d ,it is recommended to set the target of blood pressure lowering to < 125/ 75 mmHg (mean arterial pressure < 92 mmHg). (Ⅲ)
C: For patients with blood creatinine < 600 μmol/ L and total urinary protein excretion rate ≤ 1 g/ d, it is recommended to set the BP target at < 130/ 80 mmHg (mean arterial pressure < 98 mmHg). (Ⅳ)
A: For the conventional treatment of hypertension in patients with glomerulonephritis, angiotensin-converting enzyme inhibitors are preferred
(Ⅰb) (Ⅰb)
B: For the treatment of hypertension in patients with glomerulonephritis, angiotensin-converting enzyme inhibitors are preferred over calcium channel blockers because they provide better renoprotection. (Ⅲ)
B: Angiotensin II receptor antagonists can be used as an alternative to angiotensin-converting enzyme inhibitors for the treatment of hypertension in patients with glomerulonephritis. (Ⅲ)
GPP:Angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists may be used to reduce urinary protein in patients with glomerulonephritis not associated with hypertension.
GPP: In patients with blood creatinine > 265 μmol/L, angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists should be used with special caution and blood creatinine and potassium levels should be monitored regularly.
A: A low-protein diet should be considered for patients with severe renal insufficiency (creatinine > 350 μmol/L), but should be considered carefully to avoid malnutrition and its potential adverse consequences. (Ⅰa)
A: Lipid-lowering therapy does not provide renoprotective effects in patients with glomerular disease. (Ⅰb)
C:Lipid-lowering therapy may provide cardiovascular benefits in patients with glomerular disease. ( Ⅳ)
Management of microsomal lesion nephritis
A: High-dose prednisolone is recommended as initial treatment for nephrotic syndrome due to microsomal nephritis. ( Ⅰb)
A:Dose reduction and discontinuation of prednisolone should be done after the nephrotic syndrome has resolved. ( Ⅰb)
B:Cytotoxic therapy with cyclophosphamide is indicated for patients with frequent relapses, hormone-dependent and hormone-resistant types of nephrotic syndrome due to microscopic lesional nephritis. (Ⅲ)
GPP: Patients preparing for cyclophosphamide therapy should be informed of the potential infertility/infertility risks of the therapy; male patients should be advised to consider storage of their sperm.
A: Cyclosporine A may be used to treat frequently recurring, hormone-dependent and hormone-resistant types of nephrotic syndrome caused by microdegenerative nephritis. (Ⅰb)
B:Renal function should be monitored regularly in patients with nephrotic syndrome caused by microscopic nephritis treated with cyclosporine A. Repeat renal biopsy should be performed after 1 year of cyclosporine A treatment to detect histological evidence of nephrotoxicity. (III)
Management of focal segmental glomerulosclerosis
B: High-dose prednisolone should be used as first-line therapy in patients with nephrotic syndrome caused by focal segmental glomerulosclerosis. The dose should be tapered slowly after remission is achieved, and a total course of at least 6 months is required. (III)
B: Cytotoxic therapy with cyclophosphamide may be considered in hormone-dependent patients with nephrotic syndrome due to focal segmental glomerulosclerosis or with hormone-related side effects. (III)
B: Cytotoxic therapy can be used as an alternative therapy for hormone-resistant nephrotic syndrome caused by focal segmental glomerulosclerosis. (III)
GPP: Patients preparing for cyclophosphamide therapy should be informed of the potential infertility/infertility risk of the therapy; male patients should be advised to consider storage of their sperm.
A: Cyclosporine A may be considered in hormone-resistant focal segmental glomerulosclerosis resulting in nephrotic syndrome at a starting dose of 3-5 mg/kg/day, with prolonged application to maintain remission if sustained remission is not achieved. (Ⅰ b)
C: There is no reliable evidence that nephrotic syndrome due to focal segmental glomerulosclerosis can benefit from other therapies. ( Ⅳ)
Management of IgA nephropathy
C: There is no treatment recommended for patients with IgA nephropathy with simple hematuria without proteinuria, and they should be monitored regularly (every 3 to 12 months) for the development of proteinuria. (IV)
C: There are no treatment options recommended for patients with IgA nephropathy with asymptomatic hematuria and urinary protein between 0.15 and 1 g/d, lacking other adverse clinical and histologic indications. Urine protein should be monitored every 3 to 12 months. (Ⅳ)
A: Angiotensin-converting enzyme inhibitors are recommended for the treatment of hypertension in patients with IgA nephropathy (Ⅰb)
A: Angiotensin-converting enzyme inhibitors are recommended for patients with IgA nephropathy with normal blood pressure and urine protein ≥ 1 g/d. (Ⅰb)
B: Angiotensin II receptor antagonists and angiotensin-converting enzyme inhibitors have similar indications for the treatment of patients with IgA nephropathy. (Ⅱa)
B: Angiotensin II receptor antagonists and angiotensin-converting enzyme inhibitors can be combined to treat patients with IgA nephropathy with urinary protein ≥ 1 g/d. (Ⅱb)
A: For patients with IgA nephropathy with urine protein ≥ 1 g/d, a combination of dipyridamole and low-dose warfarin is recommended. Abnormal renal function is not a contraindication to its use. (Ⅰb)
A: Fish oil supplementation is not beneficial in every patient with IgA nephropathy. ( Ⅰa)
C:Fish oil supplementation may be used in patients with IgA nephropathy with urinary protein >3g/ d. ( Ⅳ)
B: Prednisolone should be used in patients with IgA nephropathy with minor histologic changes suggested by renal biopsy, at a starting dose of 1 mg/ kg/day, reduced after 4-6 weeks, for a total duration of 3-4 months. (IIb)
B: For patients with IgA nephropathy with minor histological changes on renal biopsy, if relapsed, hormone resistant or hormone dependent, cyclophosphamide should be used at a dose of 1.5-2.0 mg/kg daily for 2-3 months in combination with low dose prednisolone. (Ⅱa)
C: In patients with IgA nephropathy with minor histologic changes suggested by renal biopsy, if hormonal and cyclophosphamide therapy fails, cyclosporine A may be used at a starting dose of 5 mg/kg daily for 6-12 months, along with low-dose prednisolone. (Ⅳ)
C: Patients with IgA nephropathy who do not have mild histologic changes, similar to those with mild histologic lesions, may be treated with prednisolone, cyclophosphamide, or cyclosporine A. (IV)
GPP: However, the response to therapy in these patients is not encouraging, and therefore excessive immunosuppression in non-responders should be avoided.
C: In patients with acute renal failure due to IgA nephropathy with massive crescent formation, a standardized therapy applicable to other types of crescentic nephritis is recommended. The first treatment is methylprednisolone shock, followed by oral prednisolone, cyclophosphamide, dipyridamole, and warfarin. Plasma exchange and intravenous immunoglobulin therapy may also be used. (Ⅳ)
C: There is no specific therapy recommended for patients with acute renal failure due to IgA nephropathy with minimal histologic changes. (Ⅳ)
GPP: There is no specific therapy recommended for patients with recurrent IgA nephropathy after renal transplantation, and the treatment plan is similar to that for primary disease.
Management of membranous nephropathy
C: Patients with membranous nephropathy should be excluded from secondary causes, especially autoimmune diseases, infections, drugs, and malignancies. (Ⅳ)
B: Patients with primary membranous nephropathy with nephrotic syndrome or histologic changes of stage III or IV should receive immunosuppressive therapy because of the risk of developing end-stage renal failure. (Ⅱb)
B: There is no evidence of benefit from immunosuppressive therapy in patients with non-nephrotic range proteinuria, normal renal function, or histologic changes of stage I or II. (IIb)
B: Immunosuppressive therapy should be administered to patients with primary membranous nephropathy with progressive renal insufficiency. (Ⅲ)
A:Nephrotic syndrome due to membranous nephropathy may be treated with hormones alone to induce remission of proteinuria. ( Ⅰb)
A: There is no evidence of long-term efficacy of hormone therapy in patients with membranous nephropathy. ( Ⅰa)
A: Patients with membranous nephropathy who are at high risk of developing end-stage renal failure may be considered for a combination of alkylating agents and hormones for 6 months. (Ⅰ a)
B: Because alkylating drugs are associated with drug-related toxicity, these patients should be monitored closely before and after treatment. (Ⅲ)
A: For patients with membranous nephropathy with renal insufficiency, daily oral cyclophosphamide should be considered.
A: For patients with membranous nephropathy with renal insufficiency, daily oral cyclophosphamide for 12 months should be considered in combination with hormones to prevent renal failure. (Ⅰb)
A: Patients with membranous nephropathy who are at high risk of developing end-stage renal failure should be treated with a combination of cyclosporine A and hormones for 6 months. (Ⅰb)
A: Patients with membranous nephropathy with progressive renal insufficiency should receive 12 months of cyclosporine A therapy. (Ⅰb)
Management of acute glomerulonephritis
A: Corticosteroids, cytotoxic therapy and plasma exchange should be used for acute glomerulonephritis due to anti-glomerular basement membrane antibodies. (Ⅰb)
C:Corticosteroid therapy for acute progressive glomerulonephritis caused by anti-glomerular basement membrane antibodies should include methylprednisolone shock and subsequent oral prednisolone. (Ⅳ)
A: For patients with acute progressive glomerulonephritis due to anti-glomerular basement membrane antibodies, plasma exchange with a daily exchange volume of 4 L for 14 d or treatment until the antibodies disappear is recommended. (Ⅰb)
B: For oligoimmune complex acute glomerulonephritis, methylprednisolone shock followed by oral prednisolone 1 mg/kg/day is recommended.(Ⅱa)
B:Cyclophosphamide oral or monthly intravenous shock therapy can be used to treat patients with oligoimmune complex acute glomerulonephritis. ( Ⅱ a)
B:Plasma exchange is indicated for patients with pulmonary hemorrhage, oligoimmune complex type acute glomerulonephritis, and severe renal disease in which conventional therapy has failed. (Ⅲ)
B:For patients with acute progressive glomerulonephritis due to Wegener’s granulomatosis ,oral or intravenous cyclophosphamide can be administered. (Ⅱa)
B: For patients with acute progressive glomerulonephritis due to Wegener’s granulomatosis, high-dose corticosteroids should be administered orally or by shock therapy. (Ⅱa)
B: Plasma exchange is not indicated in patients with acute progressive glomerulonephritis due to Wegener’s granulomatosis. (III)
Management of thylakoid capillary glomerulonephritis
B:Treatment of adult and pediatric patients with primary mesenteric capillary glomerulonephritis with massive proteinuria, tubulointerstitial disease, or impaired renal function. (Ⅲ)
A: High-dose corticosteroid therapy should be administered to pediatric patients with type I tegumentary capillary glomerulonephritis who are at high risk of progression to renal failure. (Ⅰb)
B: High-dose corticosteroid therapy is indicated in children with type II tegumentary capillary glomerulonephritis who are at high risk of progression to renal failure. (III)
B: There is no evidence that corticosteroid therapy is beneficial in adults with tethered capillary glomerulonephritis. (Ⅲ)
A: Cytotoxic therapy is not recommended for patients with primary tegumentary capillary glomerulonephritis. ( Ⅰb)
B: Dipyridamole and aspirin are recommended for adults with primary tegumentary capillary glomerulonephritis who are at high risk of developing renal failure. (III)
Management of nephrotic syndrome in children
A: In pediatric patients with first-episode nephrotic syndrome, prednisolone should be given orally at 60 mg/m2 daily (maximum dose 80 mg/d) for 4 weeks, followed by 40 mg/m2 orally every other day for 24 weeks, and finally tapered over a period of 4 weeks. (Ⅰa)
A: For the treatment of nephrotic syndrome in children, prednisolone should be administered in the morning. (Ⅰb)
A: For relapsing pediatric nephrotic syndrome, prednisolone should be given orally at 60 mg/m2 (maximum dose 80 mg/d) daily (minimum 14d) until urine protein is negative for three consecutive days. Prednisolone should then be administered orally every other day for
40 mg/ m for 24 weeks and then tapered over a period of 4 weeks. (Ⅰb)
C: Patients with frequent relapses of childhood nephrotic syndrome may receive relapse therapy during the relapse period, followed by alternate days of
0. 1 to 0.5 mg/ kg of prednisolone for 3 to 6 months. (Ⅳ)
B: 2.5 mg/ kg levamisole orally every other day for 6-12 months can be used to treat pediatric patients with frequent relapses of nephrotic syndrome. (Ⅱa)
A: For the treatment of recurrence in children with frequent relapses of nephrotic syndrome, oral cyclophosphamide 2-2.5 mg/ kg daily or azelaic acid 0.15 mg/ kg daily for 8 weeks. (Ⅰa)
GPP: For hormone-dependent pediatric nephrotic syndrome patients, repeat the prednisolone relapse regimen followed by oral prednisolone 0. 1-0.5 mg/kg every other day for 6-12 months.
A: For hormone-dependent or frequently relapsing pediatric nephrotic syndrome patients, levamisole 2.5 mg/ kg should be given orally every other day for 6 to 12 months. (Ⅰb)
B: For hormone-dependent pediatric nephrotic syndrome patients, oral cyclophosphamide 2-2.5 mg/ kg daily or benzodiazepine 0.15 mg/ kg daily for 8 to 12 weeks. (Ⅲ)
A::Patients with hormone-dependent pediatric nephrotic syndrome should receive oral cyclosporine A 6 mg/ kg daily.( Ⅰb)
C: :Oral cyclosporine A for one year may be used to treat patients with hormone-dependent nephrotic syndrome. ( Ⅳ)
C: In patients with hormone-resistant pediatric nephrotic syndrome, renal biopsy is recommended to exclude other glomerular pathological changes. (Ⅳ)
C: Hyperlipidemia treatment and diuretics and intravenous albumin are recommended for symptomatic management of severe edema in patients with hormone-resistant pediatric nephrotic syndrome. (Ⅳ)
C:Oral cyclophosphamide 2 to 2.5 mg/ kg daily for 12 weeks may be used to treat patients with hormone-resistant microdegenerative pediatric nephrotic syndrome. (Ⅳ)
B: Oral cyclosporine A 6 mg/ kg daily may be used to treat hormone-resistant pediatric patients with nephrotic syndrome. ( Ⅲ)
GPP:Cyclosporine A can be maintained for 2 years in the treatment of hormone-resistant pediatric nephrotic syndrome patients.