Obtaining Tissue Diagnosis Before Initiation of Corticosteroids–Reply–I

We thank Dr Jaitovich for his insightful comments. He states that standardized treatment of rapidly progressive glomerulonephritis requires immediate therapy to avoid progression to end-stage renal disease. We agree with that statement. However, prescribing a combination of high-dose corticosteroids and cyclophosphamide is not justifiable without an eventual tissue biopsy unless the diagnosis can be obtained by other means or there are contraindications to biopsy. This does not mean that a patient cannot be started on treatment with high-dose corticosteroids alone prior to a biopsy specimen being obtained. In fact, this is our practice for patients with rapidly progressive glomerulonephritis; in the current case, high-dose corticosteroid therapy was initiated 4 days before performance of the renal biopsy. Cyclophosphamide therapy requires at least 10 to 14 days before its immunosuppressive effects are exerted, and it is the anti-inflammatory effect of high-dose corticosteroids that initially controls disease activity.