New perspectives in treatment of glomerulonephritis

In chronic glomerulonephritis (GN) the development of the tissue damage and progression to fibrosis is related to the individual immune response which brings about excessive inflammation, failure to activate regression and glomerular repair and excessive fibrogenic activity. Therefore, the present standard treatment of GN has two aims, to fight the acute inflammation and to inhibit the progressive renal fibrosis. New avenues in the anti-inflammatory and immunosuppressive treatment of the active phase of glomerular diseases include the use of drugs proven to be of value in organ transplantation (mycophenolate mofetil, rapamycin or anti-immune adhesion and anti-co-stimulatory molecules). Interest has recently focused on anti-inflammatory cytokines (monoclonal antibodies, peptidic antagonists or anti-sense oligonucleotides against TNF-alpha, anti-PDGF-beta, anti-TGF-beta and cytokine receptor antagonists) and anti-inflammatory natural cytokines (such as IL4, IL10, IL13 or low doses of TGFbeta). Other drugs may act by depleting B cells (such as anti-CD20 monoclonal antibody) or on several immune pathways, such as thalidomide or anti-cyclooxygenase 2. Several anti-sclerogenic drugs are already used for treatment of the chronic phase of glomerular diseases, such as antagonists of angiotensin II, statins and antioxidants. Other drugs are still experimental, including endothelin receptor antagonists and neutral endopeptidase or vasopeptidase inhibitors and other drugs operating on extracellular matrix accumulation/degradation mechanisms, e.g., pirfenidone. There are extremely interesting developments concerning activators of endogenous anti-inflammatory mechanisms, such as those regulated by peroxisome proliferator activated receptors. There is a need for successful treatment of chronic GN in childhood. This short review of the most promising new drugs shows there is reason to believe that the next decade will provide exciting new tools for the treatment of these diseases in children.