Glomerular diseases and Immunosuppression in COVID-19 Times

Patients with Nephrotic Syndrome and Glomerulonephritis like Systemic Lupus Erythematosus(SLE), ANCA associated Glomerulonephritis and patients with other glomerular diseases, who are on moderate to high doses of immunosuppression, are at an increased risk of sever COVID infection because of their immunosuppressed state. However there are no studies to quantify the increase in risk in relation to the amount of immunosuppressant medications or their duration of use. Hence there is a lot of uncertainty regarding the management of these patients amongst the nephrology fraternity. We acknowledge that presently there is no data on this aspect, and what is being suggested is based on scientific logic and extrapolation of evidence from other infections. A simple way to evaluate these patients is to classify them into newly diagnosed patients and those on follow up on immunosuppressant medications. Newly diagnosed patients with Idiopathic nephrotic syndrome due to MCD, FSGS IgA Nephropathy, and Membranous Nephropathy as well as patients with SLE, ANCA associated GN with normal renal functions should be managed conservatively with diuretics, salt restriction and use of ACEI or ARBS. Unless there is a progressive deterioration of renal functions, steroids and immunosuppressive agents should be withheld. For a Follow-up Patients on Immunosuppression: As per the present evidence, patients should plan to complete standard induction medication unless directed otherwise by their renal team. A risk stratification approach is suggested to help manage these patients. Some patients, particularly those on steroids, intravenous cyclophosphamide, and biologics, will be significantly immunosuppressed and should, therefore, be considered ‘high risk’. This is particularly true in the induction phase of their treatment. Others on steroid monotherapy may be at intermediate risk . If doing well, all patients should continue to take their maintenance medication unless directed otherwise by their treating team. Patients should stay on their maintenance immunosuppression and steroid, provided they are infection-free. Immunosuppressive therapy needs to be reviewed on a case by case basis balancing the risk of inadequately treated disease, or acute relapse, against the risk of the effect of COVID-19 infection in the individual patient. Patients on long term glucocorticoids (steroids, prednisolone) SHOULD NOT stop these abruptly. Patients receiving hydroxychloroquine SHOULD CONTINUE this as it may afford some protection against COVID-19 For isolation these patients should be risk-stratified into the following three groups: Group A (High Risk): These patients are at the highest risk because of concurrent use of immunosuppressive agents. They should all be advised to self-isolate for at least 12 weeks. Group B (intermediate risk): We suggest that these patients need not to self-isolate but may be moved into Group A at a later stage as more data emerges. These include the following patients: Group C: We suggest that these patients may not require self-isolation in the first instance but should follow all hygiene measures listed below. You should continue to be in touch with your treating team, because of the need to optimize immunosuppression. However hospital visits can be minimised and, instead, use Teleconsults with your nephrologist for triaging. Several new drugs are being tested. Anti-viral therapy can be given off-label depending on availability and local practices.