Treatment of kidney damage with nodular periarteritis

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

Treatment of nodular polyarteritis is effective with the optimal combination of glucocorticides and cytostatics.

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

Indications for the appointment of cytotoxic agents with nodular polyarteritis are severe renal damage with a hypertension stand, generalized vasculitis with organ damage, ineffectiveness or contraindications to the appointment of glucocorticoids. For treatment, azathioprine and cyclophosphamide are used. Cyclophosphamide is more effective in rapidly progressing disease and severe arterial hypertension. In other cases, both drugs are equivalent, but azathioprine is more easily tolerated and has fewer side effects. There is also a regime in which cyclophosphamide is used to induce remission, and as a maintenance therapy, azathioprine is administered.

• Azathioprine and cyclophosphamide in the acute period is prescribed in a dose of 2-3 mg / kg of body weight per day (150-200 mg) for a period of 6-8 weeks, followed by
  
  transition to a maintenance dose of 50-100 mg / day, which the patient takes at least a year.
• In the case of severe arterial hypertension and increasing renal failure, a pulse-therapy with cyclophosphamide at a dose of 800-1000 mg intravenously monthly is performed. With CF less than 30 ml / min, the dose of the drug should be reduced by 50%.
• In severe cases, the intervals between administrations are reduced to 2-3 weeks, the dose of the drug is reduced to 400-600 mg per procedure. In these situations, the pulse-therapy with cyclophosphamide can be combined with plasmapheresis sessions, but the advantages of this regimen are not proven.

The total duration of immunosuppressive therapy in patients with nodular polyarteritis is not defined. Since the disease is rarely marked exacerbation, it is recommended to perform active treatment with glucocorticoids and cytostatics for no more than 12 months, however in each specific case this term should be determined individually.

Treatment of nodular periarteritis associated with HBV infection currently requires the use of antiviral drugs: interferon alfa, vidarabine and, in recent years, lamivudine. Indication for their purpose is the absence of severe renal failure (creatinine concentration in the blood not more than 3 mg / dL), heart failure, irreversible changes in the CNS, complicated abdominal syndrome. At the beginning of the treatment, antiviral drugs are combined with glucocorticoids, which are prescribed for a short time to suppress high disease activity and are quickly canceled without switching to supportive therapy. Antiviral therapy should be combined with the conduct of plasmapheresis sessions, since it is believed that monotherapy with antiviral drugs can not control the majority of life-threatening manifestations of the disease. Treatment with plasmapheresis, unlike glucocorticoids and cyclophosphamide, does not affect the replication of HBV and allows controlling the activity of the disease without the addition of immunosuppressive drugs. Sessions of plasmapheresis should be conducted before seroconversion is achieved.

In the treatment of nodular polyarteritis an important role is assigned to symptomatic therapy, especially control of hypertension. Stabilization of blood pressure with the help of antihypertensive drugs of different groups (ACE inhibitors, beta-adrenoblockers, slow calcium channel blockers, diuretic drugs), prescribed in various combinations, allows to slow the progression of renal failure, reduce the risk of vascular accidents (myocardial infarction, stroke), circulatory insufficiency .

Renal Replacement Therapy with Nodular Polyarteritis

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