Treatment of kidney damage in periarteritis nodosa

The choice of therapeutic regimen and drug doses is determined by clinical and laboratory signs of disease activity (fever, weight loss, dysproteinemia, increased ESR), the severity and rate of progression of damage to internal organs (kidneys, nervous system, gastrointestinal tract), the severity of arterial hypertension, and the presence of active HBV replication.

Treatment of polyarteritis nodosa is effective with an optimal combination of glucocorticoids and cytostatics.

• In the acute period of the disease, before the development of visceral lesions, prednisolone is prescribed at a dose of 30-40 mg/day. Treatment of nodular polyarteritis with severe damage to internal organs should begin with pulse therapy with methylprednisolone: 1000 mg intravenously once a day for 3 days. Then prednisolone is prescribed orally at a dose of 1 mg/kg of body weight per day.
• After achieving the clinical effect: normalization of body temperature, reduction of myalgia, cessation of weight loss, reduction of ESR (on average within 4 weeks) - the dose of prednisolone is gradually reduced (5 mg every 2 weeks) to a maintenance dose of 5-10 mg/day, which must be taken for 12 months.
• In the presence of arterial hypertension, especially malignant, it is necessary to reduce the initial dose of prednisolone to 15-20 mg/day and reduce it rapidly.

Indications for prescribing cytostatics for polyarteritis nodosa include severe kidney damage with persistent arterial hypertension, generalized vasculitis with organ damage, ineffectiveness or contraindications to prescribing glucocorticoids. Azathioprine and cyclophosphamide are used for treatment. Cyclophosphamide is more effective in rapidly progressing disease and severe arterial hypertension. In other cases, both drugs are equivalent, but azathioprine is better tolerated and has fewer side effects. There is also a regimen in which cyclophosphamide is used to induce remission, and azathioprine is prescribed as maintenance therapy.

• Azathioprine and cyclophosphamide in the acute period are prescribed at a dose of 2-3 mg/kg of body weight per day (150-200 mg) for a period of 6-8 weeks, followed by
  

  The transition to a maintenance dose of 50-100 mg/day, which the patient takes for at least a year.

• In case of severe arterial hypertension and increasing renal failure, pulse therapy with cyclophosphamide is administered at a dose of 800-1000 mg intravenously monthly. If the CF is less than 30 ml/min, the dose of the drug should be reduced by 50%.
• In severe cases, the intervals between injections are reduced to 2-3 weeks, the dose of the drug is reduced to 400-600 mg per procedure. In these situations, pulse therapy with cyclophosphamide can be combined with plasmapheresis sessions, but the benefits of such a regimen have not been proven.

The total duration of immunosuppressive therapy in patients with polyarteritis nodosa has not been determined. Since exacerbations of the disease are rare, it is recommended to conduct active treatment with glucocorticoids and cytostatics for no more than 12 months, but in each specific case this period should be determined individually.

Treatment of periarteritis nodosa associated with HBV infection currently requires the use of antiviral drugs: interferon alpha, vidarabine and, in recent years, lamivudine. The indication for their use is the absence of severe renal failure (creatinine concentration in the blood no more than 3 mg / dl), heart failure, irreversible changes in the central nervous system, complicated abdominal syndrome. At the beginning of treatment, antiviral drugs are combined with glucocorticoids, which are prescribed for a short period to suppress high disease activity and are quickly discontinued without switching to maintenance therapy. Antiviral therapy should be combined with plasmapheresis sessions, since, as is believed, most life-threatening manifestations of the disease cannot be controlled with monotherapy with antiviral drugs. Plasmapheresis treatment, unlike glucocorticoids and cyclophosphamide, does not affect HBV replication and allows disease activity to be controlled without the addition of immunosuppressive drugs. Plasmapheresis sessions should be performed until seroconversion is achieved.

In the treatment of polyarteritis nodosa, symptomatic therapy plays an important role, especially the control of arterial hypertension. Stabilization of arterial pressure with the help of antihypertensive drugs of different groups (ACE inhibitors, beta-blockers, calcium channel blockers, diuretics), prescribed in various combinations, helps slow the progression of renal failure, reduce the risk of vascular accidents (myocardial infarction, stroke), and circulatory failure.

Renal replacement therapy for polyarteritis nodosa

Hemodialysis is used to treat patients with polyarteritis nodosa when they develop terminal renal failure. It is recommended to continue immunosuppressive therapy against the background of hemodialysis for another year after the development of remission of the disease. Reports on kidney transplantation in patients with polyarteritis nodosa are few.