Received: 28.02.18
Accepted: 30.04.18
Abstract
Glomerular diseases are a common cause of chronic kidney disease in several low-to-middle-income
countries (LMIC). Additionally, they represent up to 52% of patients with end-stage renal disease
(ESRD) in Africa. Current guideline recommendations for the treatment of glomerular diseases may
not always be applicable in LMIC due to various challenges related to disease diagnosis and the
availability of medicines. A treatment approach that starts with disease diagnosis and proper use
of adjuvant therapies mainly targeted at blood pressure and proteinuria reduction is an effective
therapeutic option and is recommended for patients in LMIC with glomerular pathologies. The use
of immunosuppressive therapies in adults with glomerular diseases should, as far as is possible,
be guided by the histological diagnosis obtained through renal biopsy. Prednisone and
cyclophosphamide still form the bulk of treatment for glomerular diseases in most countries.
Due to the adverse effects associated with immunosuppression, prednisone and cyclophosphamide
use must be carefully weighed against the risk of potential side effects, and there is a need for
frequent monitoring to assess treatment efficacy, patient response, and adverse effects. It is not
advisable to use immunosuppressive drugs (e.g., cyclosporine) that require monitoring of plasma
levels in centres where such facilities are not available, given the possible associated nephrotoxicity.
The purpose of this narrative review is to provide an update on the treatment of common
glomerular diseases and to highlight simple approaches to treatment in LMIC. Knowledge of
guideline recommendations on the treatment of various glomerular diseases will provide important
understanding on useful therapeutic approaches.
Region Male Mean Sample MCD Mes MCGN FSGS MGN IgAN Cres LN Hep B Amyloid HIVAN
(%) age in size (%) PGN (%) (%) (%) (%) GN (%) (%) (%) (%)
years (%) (%)
(range)
Africa;* Okpechi 45.2– Data not 12,093 16.5 9.2 11.8 15.9 6.6 2.8 2.0 7.7 8.3 2.9 1.0
et al.,14 2016 68.8 available
(1–79)
Latin America;† 36.4 30.0 2,561 6.8 2.4 2.8 15.8 11.1 6.1 4.7 38.1 NR 1.4 NR
O'Shaughnessy (17–71)
et al.,15 2017
China;‡ Xu 46.5 35.2 4,931 1.8 14.4 1.2 3.6 13.3 43.5 0.7 47.4 10.6 2.7 NR
et al.,16 2016 (10–76)
India; Beniwal 66.1 30.3 622 21.1 6.4 9.6 10.5 15.0 7.4 1.9 7.6 NR 5.9 NR
et al.,17 2016 (12–70)
Iran; Ossareh 54.2 36.5 1,407 8.3 0.9 5.5 10.0 26.8 11.0 5.8 11.0 NR 3.3 NR
et al.,18 2010 (12–84)
*Represents data from 13 countries: Cameroon, Democratic Republic of Congo, Egypt, Ghana, Kenya, Morocco, Namibia,
Nigeria, Senegal, South Africa, Sudan, Tunisia, Zimbabwe. †Represents data from three countries: Brazil, Colombia, and
Mexico. ‡Data presented separately for primary and secondary GN.
CresGN: Crescentic GN; FSGS: focal segmental glomerulosclerosis; GN: glomerulonephritis; Hep B: hepatitis B; HIVAN: human
immunodeficiency virus associated nephropathy; IgAN: IgA nephropathy; LN: lupus nephritis; MCD: minimal change disease;
MCGN: mesangiocapillary GN; MGN: membranous GN; MesPGN: mesangial proliferative GN; NR: not reported.
However, in most developing countries, including CKD in this population.10 Even within developed
those in Asia, Africa, and Latin America, countries, glomerular diseases tend to play a
glomerular diseases remain a major cause of major role in the epidemiology of kidney diseases
CKD and of incident dialysis patients.5-7 In various among the poorer or minority groups.11
instances, the cause of CKD remains unknown
The recent Global Kidney Health Atlas (GKHA)12
and thus the condition is labelled as CKD of
publication by the International Society of
unknown aetiology.
Nephrology (ISN) showed that use of guidelines
Data from 12 African countries showed that in treating kidney diseases is particularly reduced
glomerular diseases were responsible for in low-income countries. This suggests that
10.2–52.0% of patients diagnosed with ESRD use of guidelines, such as those of the Kidney
in adults and children (Morocco: 10.2%; South Diseases Improving Global Outcomes (KDIGO),13
Africa: 52.0%).8 Furthermore, data from a large for treating glomerular diseases in LMIC may
Chinese study9 that reviewed 65,074 dialysis also be low. The purpose of this review is to
patients from 27 provinces showed the main provide an update on the treatment of common
glomerular diseases and to highlight simple
causes of ESRD were glomerulonephritis (GN)
approaches to treatment in LMIC.
(45%), diabetes (19%), hypertension (13%),
polycystic kidney disease (2%), and others or
unknown (20%). An assessment of children EPIDEMIOLOGY OF
with CKD in Guatemala showed that diagnosis GLOMERULONEPHRITIS IN
with glomerular disease was associated with LOW-TO-MIDDLE-INCOME COUNTRIES
a significant risk of progression to ESRD in
comparison with other diagnoses (hazard ratio: Table 1 provides a summary of the frequency
4.84; 95% confidence interval: 1.31–17.91; p=0.02), of common patterns of glomerular diseases
underlining the importance of GN as a cause of seen in selected LMIC.14-18 Due mainly to a
Adjuvant Alkylating
Corticosteroids Antimetabolites Calcineurins Antibodies Apheresis
therapies agents
MGN
MCD MCD
Usually for LN LN Anti-GBM
Indications FSGS MGN
All GN most GN if ISP AAV AAV disease
MGN LN
is indicated Anti-GBM disease IgAN (with cres) AAV
LN AAV
Other cres GN
Sepsis Nephrotoxicity
Cushingoid Leucopenia Fever Fever
Complications Leucopenia Metabolic
Rare Infections GIT Chills Chills
Anaemia abnormalities
Dysglycaemia disturbances Nausea/vomiting Urticaria
Infertility Cosmetic changes
EMJ
Cost $ - $$ $ $–$$ $$–$$$ $$$–$$$$ $$$$$ $$$$$
AAV: antineutrophil cytoplasmic autoantibody-associated vasculitis; ACTH: adrenocorticotrophic hormone; BP: blood pressure; cres: crescentic; FSGS:
focal segmental glomerulosclerosis; GBM: glomerular basement membrane; GIT: gastrointestinal tract; GN: glomerulonephritis; IgAN: immunoglobulin A nephropathy;
ISP: immunosuppression; LN: lupus nephritis; MCD: minimal change disease; MGN: membranous glomerulonephritis; RAAS: renin angiotensin aldosterone system.
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