Philibert David, Cattran Daniel
University Health Network, Toronto General Research Institute, Toronto, ON, Canada.
Nat Clin Pract Nephrol. 2008 Oct;4(10):550-9. doi: 10.1038/ncpneph0915. Epub 2008 Aug 26.
Membranous nephropathy, focal segmental glomerulosclerosis and IgA nephropathy are the most commonly recognized types of primary glomerulonephritis that progress to end-stage renal disease. Persistent proteinuria is a major determinant of such progression. Reduction of proteinuria slows progression of renal disease and improves renal survival, but many of the agents used to reduce proteinuria carry a considerable risk of toxicity. The assessment of benefit versus risk of these medications can be further complicated by the temporal disconnect between the onset of benefit and of serious adverse events. In addition, relapses are common in these disorders and there is often a need for retreatment. Such retreatment might lead to repeated and/or prolonged drug exposure and to the oversight or underestimation of the cumulative dose of these agents because of the potentially extended interval between relapses. Consequently, it is very important to constantly review each patient's status and take into account their age, comorbid conditions and cumulative drug exposure when assessing treatment options. The potentially delayed development of adverse events also emphasizes the need for long-term surveillance of patients who receive immunosuppressive treatment for glomerular disease, often well beyond their drug exposure period and even when the treatment has been successful.
膜性肾病、局灶节段性肾小球硬化症和IgA肾病是最常见的可进展为终末期肾病的原发性肾小球肾炎类型。持续性蛋白尿是这种疾病进展的主要决定因素。降低蛋白尿可减缓肾病进展并提高肾脏存活率，但许多用于降低蛋白尿的药物具有相当大的毒性风险。这些药物的获益与风险评估可能会因获益与严重不良事件发生时间的脱节而进一步复杂化。此外，这些疾病中复发很常见，且常常需要再次治疗。这种再次治疗可能导致反复和/或长期接触药物，并且由于复发间隔可能延长，可能会忽视或低估这些药物的累积剂量。因此，在评估治疗方案时，持续审查每位患者的状况并考虑其年龄、合并症和累积药物暴露情况非常重要。不良事件可能延迟出现这一点也凸显了对接受肾小球疾病免疫抑制治疗的患者进行长期监测的必要性，这种监测通常远远超出其药物暴露期，甚至在治疗成功后仍需进行。
