Book Review

The Treatment of Glomerulonephritis

N Engl J Med 2000; 342:63January 6, 2000

Article

The Treatment of Glomerulonephritis
(Developments in Nephrology. Vol. 40.) Edited by C.D. Pusey. 227 pp., illustrated. Boston, Kluwer Academic, 1999. $129. ISBN: 0-7923-5332-3

In 1765, Domenico Cotugno described a soldier with dropsy (the nephrotic syndrome) who had a response to treatment with potassium bitartrate. Dr. Cotugno was apparently satisfied, and on the basis of this case, he concluded that he had made the right therapeutic decision. For a long time thereafter, many nephrologists, like Dr. Cotugno, treated glomerular diseases with corticosteroids, immunosuppressants, plasma exchange, or other methods without having a solid scientific basis for such treatments. In fact, the effectiveness of these treatments remains uncertain and controversial.

In recent years, there has been progress in understanding the pathogenesis of glomerulonephritis. Some new diagnostic tools (such as antineutrophil cytoplasmic antibodies) have become available, and the prognosis for patients with certain types of glomerulonephritis has improved substantially. Nevertheless, therapeutic protocols for various types of glomerulonephritis are frequently confusing and controversial because of the paucity of data from prospective, randomized trials. In addition, the trials that have been reported have generally involved small numbers of patients with heterogeneous forms of glomerulonephritis, and the results have been conflicting.

The Treatment of Glomerulonephritis reviews current treatment options for the main types of glomerulonephritis. Each chapter has been written by one or two international experts. The book begins with reviews of immune mechanisms and the pathology of glomerular diseases, which provide a basis for understanding treatment choices. Next, there are six chapters devoted to the treatment of the most common types of primary glomerulonephritis and glomerulonephritis associated with systemic vasculitis or other systemic diseases. The last two chapters deal with glomerulonephritis in two special situations: renal transplantation and pregnancy. Many references are provided, and the chief clinical trials are reviewed.

When treating patients with glomerulonephritis, nephrologists have several, often simultaneous objectives: control of a disabling nephrotic syndrome, reduction of proteinuria in order to slow the deterioration in renal function, and prevention of end-stage renal disease. They have to weigh the potential benefits of therapy against the risks of short- and long-term complications. In this book, the chapter authors list the potential means of treatment according to the pathogenesis of the glomerular lesion (e.g., in patients with IgA nephropathy, the reduction of IgA production, removal of IgA deposits, and modification of immune and inflammatory events). The authors comment on retrospective studies, and the data from randomized, controlled trials are well reviewed. Treatment options are recommended on the basis of data from prospective trials, if available, or from retrospective studies and case reports and on the basis of the authors' own experience.

Like many of the authors, I have been disappointed by the lack of data from randomized, controlled trials with adequate statistical power to answer questions about which patients to treat, when to start treatment, and how long to continue it — even for IgA nephropathy, the most common type of glomerulonephritis. However, as a nephrologist mainly involved in clinical work, I found the information in this book helpful and interesting. Although it does not contain color figures, there are many clear tables, with important findings in bold type. The chapter authors state the objectives of each treatment, the chances of short- or long-term success, and the circumstances in which it is most likely to be successful. The information is clear, up to date, and practical.

This book will be of interest to nonspecialists, nephrologists, transplantation physicians, and clinical pathologists. My recommendation is enthusiastic, because the authors accept the fact that the ultimate test of any therapy is whether it does the patient more good than harm. They advise the reader to choose reasonable, nonaggressive approaches and point out that with drugs that can have severe side effects, it is better to withhold or stop therapy than to escalate doses.

Georges Mourad, M.D.
Hôpital Lapeyronie, 34295 Montpellier CEDEX 5, France