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Shin DH, Lee MJ, Oh HJ, Koo HM, Doh FM, Kim HR, Han JH, Park JT, Han SH, Choi KH, Yoo TH, Kang SW. Stepwise treatment using corticosteroids alone and in combination with cyclosporine in korean patients with idiopathic membranous nephropathy. Yonsei Med J 2013; 54:973-82. [PMID: 23709434 PMCID: PMC3663215 DOI: 10.3349/ymj.2013.54.4.973] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We undertook an observational study to investigate the effects of immunosuppressive treatment on proteinuria and renal function in 179 Korean idiopathic membranous nephropathy patients with nephrotic syndrome. MATERIALS AND METHODS The primary outcome was regarded as the first appearance of remission and the secondary outcomes as a decline in estimated glomerular filtration rate (eGFR) >50% or initiation of dialysis, and all-cause mortality. Seventy-two (40.2%) and 50 (27.9%) patients were treated with corticosteroids alone (C) and corticosteroids plus cyclosporine (C+C), respectively, whereas 57 (31.8%) did not receive immunosuppressants (NTx). Cyclosporine was added if there was no reduction in proteinuria of >50% from baseline by corticosteroids alone within 3 months. RESULTS There were no differences in baseline renal function and the amount of proteinuria among the three groups. Overall, complete remission (CR) was achieved in 88 (72.1%) patients by immunosuppressants. In a multivariate analysis adjusted for covariates associated with adverse renal outcome, the probability of reaching CR was significantly higher in the C [hazard ratio (HR), 4.09; p<0.001] and C+C groups (HR, 2.57; p=0.003) than in the NTx group. Kaplan-Meier analysis revealed that 5-year CR rates of C, C+C, and NTx groups were 88.5%, 86.2%, and 56.7% (p<0.001). Ten-year event-free rates for the secondary endpoints in these three groups were 91.7%, 79.9%, and 57.2% (p=0.01). CONCLUSION Immunosuppressive treatment was effective in inducing remission and preserving renal function in these patients. Therefore, stepwise treatment using corticosteroids alone and in combination with cyclosporine is warranted in these patients.
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Affiliation(s)
- Dong Ho Shin
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea
| | - Mi Jung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Jung Oh
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyang Mo Koo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Fa Mee Doh
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyoung Rae Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Tak Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Severance Biomedical Science Institute, Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
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Outcomes of tacrolimus therapy in adults with refractory membranous nephrotic syndrome: a prospective, multicenter clinical trial. Am J Med Sci 2013; 345:81-7. [PMID: 22627258 DOI: 10.1097/maj.0b013e31824ce676] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The treatment of adult refractory idiopathic membranous nephropathy with steroid and other immunosuppressant-resistant nephrotic syndrome can be a significant challenge. The authors investigated the efficacy and safety of tacrolimus (TAC) as a promising regimen. METHODS A prospective, multicenter trial was conducted in 9 nephrology centers from 2006 to 2008. Fourteen patients were enrolled. In conjunction with prednisone, TAC was started at 0.05 mg/kg/d, titrated to achieve a trough blood level of 5 to 10 ng/mL for the first 6 months, then reduced to 4 to 6 ng/mL for the subsequent 6 months. The primary endpoints included complete or partial remission. Secondary endpoints included relapse, change of clinical parameters and adverse events. RESULTS After 12 months, complete remission was achieved in 35.7% of patients and partial remission in 42.9%, yielding a response rate of 78.6%. Proteinuria, serum albumin, cholesterol, triglyceride and low-density lipoprotein were improved significantly (P < 0.001, P < 0.001, P = 0.002, P = 0.01, P = 0.004, respectively). Proteinuria and serum albumin were significantly improved (42.0% ± 13.2%, P = 0.02; 15.2% ± 4.5%, P = 0.01, respectively) even after the first month of treatment. One patient relapsed during the subsequent 6 months of follow-up. Adverse events included 2 cases of infection and 1 case each of hyperglycemia, hand tremor, sudden death (nondrug related) and diarrhea. CONCLUSIONS TAC plus prednisone may be an alternative therapeutic option for steroid and general immunosuppressant-resistant membranous nephrotic syndrome patients, with a favorable safety profile. However, given the limitation of a small number of patients in this trial, further study with a larger number and longer follow-up is needed.
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Chen Y, Schieppati A, Cai G, Chen X, Zamora J, Giuliano GA, Braun N, Perna A. Immunosuppression for membranous nephropathy: a systematic review and meta-analysis of 36 clinical trials. Clin J Am Soc Nephrol 2013; 8:787-96. [PMID: 23449768 DOI: 10.2215/cjn.07570712] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The efficacy and safety of immunosuppression for idiopathic membranous nephropathy (IMN) with nephrotic syndrome are still controversial. A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Cochrane Library, PUBMED, EMBASE, Chinese Database, and Clinical Trial Registries (June 2012) were searched to identify RCTs investigating the effect of immunosuppression on adults with IMN and nephrotic syndrome. RESULTS This review was an update (36 RCTs, 1762 participants) of the 2004 version (18 RCTs, 1025 participants). Immunosuppression significantly reduced all-cause mortality or ESRD (15 RCTs, 791 participants; risk ratio, 0.58 [95% confidence interval, 0.36-0.95]; P=0.03). However, the result was not consistent when prespecified subgroup analyses were undertaken. Immunosuppression increased complete or partial remission (CR + PR) (16 RCTs, 864 participants; 1.31 [1.01-1.70]; P=0.04) but resulted in more withdrawals or hospitalizations (16 RCTs, 880 participants; 5.35 [2.19-13.02]; P=0.002). Corticosteroids combined with alkylating agents significantly reduced all-cause mortality or ESRD (8 RCTs, 448 participants; 0.44 [0.26-0.75]; P=0.002) and increased CR + PR (7 RCTs, 422 participants; 1.46 [1.13-1.89]; P=0.004) but led to more adverse events (4 RCTs, 303 participants; 4.20 [1.15-15.32]; P=0.03). Cyclophosphamide was safer than chlorambucil (3 RCTs, 147 participants; 0.48 [0.26-0.90]; P=0.02). Cyclosporine and mycophenolate mofetil failed to show superiority over alkylating agents. Tacrolimus and adrenocorticotropic hormone significantly reduced proteinuria. CONCLUSIONS Alkylating agents plus corticosteroids had long-term and short-term benefits for adult IMN, but resulted in more withdrawals or hospitalizations.
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Affiliation(s)
- Yizhi Chen
- Chinese People's Liberation Army General Hospital, Beijing, China
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Horvatic I, Ljubanovic DG, Bulimbasic S, Knotek M, Prkacin I, Tisljar M, Galesic K. Prognostic significance of glomerular and tubulointerstitial morphometry in idiopathic membranous nephropathy. Pathol Res Pract 2012; 208:662-7. [DOI: 10.1016/j.prp.2012.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 07/31/2012] [Accepted: 08/08/2012] [Indexed: 10/27/2022]
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Hofstra JM, Debiec H, Short CD, Pellé T, Kleta R, Mathieson PW, Ronco P, Brenchley PE, Wetzels JF. Antiphospholipase A2 receptor antibody titer and subclass in idiopathic membranous nephropathy. J Am Soc Nephrol 2012; 23:1735-43. [PMID: 22956816 DOI: 10.1681/asn.2012030242] [Citation(s) in RCA: 230] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The phospholipase A(2) receptor (PLA(2)R) is the major target antigen in idiopathic membranous nephropathy. The technique for measuring antibodies against PLA(2)R and the relationship between antibody titer and clinical characteristics are not well established. Here, we measured anti-PLA(2)R (aPLA(2)R) antibody titer and subclass in a well defined cohort of 117 Caucasian patients with idiopathic membranous nephropathy and nephrotic-range proteinuria using both indirect immunofluorescence testing (IIFT) and ELISA. We assessed agreement between tests and correlated antibody titer with clinical baseline parameters and outcome. In this cohort, aPLA(2)R antibodies were positive in 74% and 72% of patients using IIFT and ELISA, respectively. Concordance between both tests was excellent (94% agreement, κ=0.85). Among 82 aPLA(2)R-positive patients, antibody titer significantly correlated with baseline proteinuria (P=0.02). Spontaneous remissions occurred significantly less frequently among patients with high antibody titers (38% versus 4% in the lowest and highest tertiles, respectively; P<0.01). IgG4 was the dominant subclass in the majority of patients. Titers of IgG4, but not IgG1 or IgG3, significantly correlated with the occurrence of spontaneous remission (P=0.03). In summary, these data show high agreement between IIFT and ELISA assessments of aPLA(2)R antibody titer and highlight the pathogenetic role of these antibodies, especially the IgG4 subclass, given the observed relationships between aPLA(2)R titer, baseline proteinuria, and outcome.
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Affiliation(s)
- Julia M Hofstra
- Radboud University Nijmegen Medical Centre, Department of Nephrology, Nijmegen, The Netherlands.
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Abstract
Exciting progress recently has been made in our understanding of idiopathic membranous nephropathy, as well as treatment of this disease. Here, we review important advances regarding the pathogenesis of membranous nephropathy. We will also review the current approach to treatment and its limitations and will highlight new therapies that are currently being explored for this disease including Rituximab, mycophenolate mofetil, and adrenocorticotropic hormone, with an emphasis on results of the most recent clinical trials.
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Affiliation(s)
- Meryl Waldman
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA.
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Abstract
Several immunosuppressive treatments have demonstrated their efficacy in idiopathic membranous nephropathy, but spontaneous remission does develop in more than 30% of patients. The availability of a validated biomarker that is easy to measure and able to accurately predict long-term outcomes would be very helpful for tailoring treatment of the disease to the individual.
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van den Brand JAJG, Hofstra JM, Wetzels JFM. Prognostic value of risk score and urinary markers in idiopathic membranous nephropathy. Clin J Am Soc Nephrol 2012; 7:1242-8. [PMID: 22595828 DOI: 10.2215/cjn.00670112] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Accurate prediction of prognosis may improve management of patients with idiopathic membranous nephropathy. This study compared the Toronto Risk Score and urinary low-molecular weight proteins. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS One hundred four patients with biopsy-proven idiopathic membranous nephropathy who presented between 1995 and 2008 with a well-preserved kidney function and nephrotic range proteinuria were included. Urinary β2-microglobulin and α1-microglobulin measurements were obtained by timed standardized measurements, and the Toronto Risk Score was calculated using data obtained from medical records. The endpoint was progression, which was defined as an increase in serum creatinine > 50% or > 25% with a concentration > 135 μmol/L. RESULTS Forty-nine patients showed progression. The area under the receiver-operating characteristics curve was 0.78 (95% confidence interval = 0.69-0.88) for the risk score versus 0.80 (0.71-0.89) and 0.79 (0.71-0.88) for urinary β2- and α1-microglobulin, respectively. Differences were not significant. Persistent proteinuria did not add accuracy to the Toronto Risk Score. Conversely, its accuracy was not reduced when data from the first 6 months of follow-up were used. Furthermore, a score based on GFR estimated with the six-variable Modification of Diet in Renal Disease equation, calculated in the first 6 months of follow-up, gave an area under the receiver-operating characteristics curve of 0.83 (0.74-0.92), which was not statistically different from other markers. CONCLUSIONS The prognostic accuracies of the Toronto Risk Score and urinary low-molecular weight proteins were not significantly different. The risk score can be calculated within 6 months of diagnosis, and a simplified risk score using estimated GFR-Modification of Diet in Renal Disease may be sufficient.
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van den Brand JAJG, Hofstra JM, Wetzels JFM. Low-molecular-weight proteins as prognostic markers in idiopathic membranous nephropathy. Clin J Am Soc Nephrol 2012; 6:2846-53. [PMID: 22157712 DOI: 10.2215/cjn.04020411] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Accurate prediction of prognosis in idiopathic membranous nephropathy (iMN) allows restriction of immunosuppressive therapy to patients at high risk for ESRD. Here we re-evaluate urinary low-molecular-weight proteins as prognostic markers and explore causes of misclassification. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a cohort of 129 patients with serum creatinine concentration <135 μmol/L and proteinuria ≥3.0 g/10 mmol, urinary α1- (uα1m) and β2-microglobulin (uβ2m) excretion rate was determined. Urinary α1m and uβ2m-creatinine ratio was also obtained. We defined progression as a rise in serum creatinine ≥50% or ≥25% and an absolute level ≥135 μmol/L. RESULTS Median survival time was 25 months, and 47% of patients showed progression. The area under the receiver operating characteristic curve for uβ2m was 0.81 (95% CI: 0.73 to 0.89). Using a threshold value of 1.0 μg/min, sensitivity and specificity were 73% and 75%, respectively. Similar accuracy was observed for the uβ2m-creatinine ratio with sensitivity and specificity of 75% and 73%, respectively, at a threshold of 1.0 μg/10 mmol creatinine. Similar accuracy was found for uα1m and uα1m-creatinine ratio. Blood Pressure and cholesterol contributed to misclassification. Repeated measurements improved accuracy in patients with persistent proteinuria: the positive predictive value of uβ2m increased from 72% to 89% and the negative predictive value from 76% to 100%. CONCLUSIONS Urinary excretion of uα2m and uβ2m predict prognosis in iMN. A spot urine sample can be used instead of a timed sample. A repeated measurement after 6 to 12 months increases prognostic accuracy.
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Affiliation(s)
- Jan A J G van den Brand
- Department of Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Sugase T, Akimoto T, Iwazu Y, Yamazaki T, Numata A, Takemoto F, Muto S, Kusano E. Minimal change nephrotic syndrome complicated with malignant ascites in a patient with type II diabetes. Intern Med 2012; 51:1885-8. [PMID: 22821106 DOI: 10.2169/internalmedicine.51.7550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A large number of renal biopsy studies have shown the concurrent presence of non-diabetic renal disease in diabetics. This report describes one such diabetic female patient with nephrotic syndrome due to minimal change glomerular disease who was successfully treated with prednisolone. Despite the remission of her nephrotic syndrome, she had gradual development of malignant ascites, which was finally interpreted to be linked to primary peritoneal carcinoma. It is necessary to bear in mind that malignancies may not only be the underlying etiology for paraneoplastic glomerular injuries, but also can be an independent pathogenic process, regardless of their nephrotic status during the overall management of the patients with ascites.
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Affiliation(s)
- Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
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Omokehinde T, El Esnawi M, Jagboto S, Arogundade R. Hemoptysis in TB Endemic Area. Think Again! Qatar Med J 2011. [DOI: 10.5339/qmj.2011.2.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This case report illustrates an acute presentation of hemoptysis in a 21-year-old man from a TB endemic region. Further clinical evaluation resulted in extensive hypercoagulability complications of nephritic syndrome due to idiopathic membranous glomerulonephritis (MGN.) This emphasizes that proteinuria seen at a subnephrotic level, or on urine dipstick in a setting where glomerular disease might not be initially apparent, may warrant a keener look.
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Affiliation(s)
- T.R. Omokehinde
- Nephrology Section, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - M.A. El Esnawi
- Nephrology Section, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - S. Jagboto
- Nephrology Section, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - R. Arogundade
- Nephrology Section, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
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Hofstra JM, Wetzels JFM. Management of patients with membranous nephropathy. Nephrol Dial Transplant 2011; 27:6-9. [PMID: 21737514 DOI: 10.1093/ndt/gfr371] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Polanco N, Gutiérrez E, Rivera F, Castellanos I, Baltar J, Lorenzo D, Praga M. Spontaneous remission of nephrotic syndrome in membranous nephropathy with chronic renal impairment. Nephrol Dial Transplant 2011; 27:231-4. [PMID: 21624942 DOI: 10.1093/ndt/gfr285] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Spontaneous remission (SR) of nephrotic syndrome, in the absence of immunosuppressive treatment, is relatively common among patients with idiopathic membranous nephropathy (IMN) and normal renal function. However, it has not been reported in patients with chronic renal impairment. METHODS All patients with IMN who had developed SR in the presence of chronic renal insufficiency were identified among the nephrology departments that belong to the Spanish Group for the Study of Glomerular Diseases (GLOSEN). Their characteristics and outcome after SR were studied. RESULTS Eleven patients were identified. All of them showed renal insufficiency and nephrotic syndrome at the time of renal biopsy. Serum creatinine (Scr) continued to increase in the following months, reaching a peak value of 2.6 ± 1.5 mg/dL (range 1.7-6.5). Angiotensin converting enzyme inhibitors or spironolactone were prescribed in 10/11 patients at renal biopsy or shortly after it. Nephrotic proteinuria persisted during the first months of follow-up, but it started to spontaneously decrease 12 ± 7 months (2-30 months) after renal biopsy. Finally, complete (nine patients) or partial (two patients) remission of nephrotic syndrome was observed. Coinciding with proteinuria remission, renal function tended to improve. Nephrotic syndrome relapsed in two patients, accompanied by a rapid deterioration of renal function. In the remaining nine patients, remission persisted throughout a follow-up of 146 ± 64 months. Mean Scr at the last visit was 1.9 ± 0.9 mg/dL and proteinuria 0.2 g/24 h. CONCLUSION SR of nephrotic syndrome can also be observed in membranous nephropathy patients exhibiting chronic renal impairment.
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Affiliation(s)
- Natalia Polanco
- Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
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McQuarrie EP, Stirling CM, Geddes CC. Idiopathic membranous nephropathy and nephrotic syndrome: outcome in the era of evidence-based therapy. Nephrol Dial Transplant 2011; 27:235-42. [PMID: 21558430 DOI: 10.1093/ndt/gfr220] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Contemporary studies analysing the long-term outcomes of patients with idiopathic membranous nephropathy and nephrotic syndrome in the era of evidence-based antiproteinuric and immunosuppressive therapies are sparse. Controversy also persists regarding which immunosuppression (IS) regimen to use. In this retrospective cohort study, we aimed to characterize time to partial remission (PR), complete remission (CR), requirement for renal replacement therapy (RRT) or death. We aimed to assess which factors predicted RRT or death and determine the impact of IS on outcome. METHODS Ninety-five consecutive adult patients attending two centres between 1997 and 2008 were identified. Baseline demographics and subsequent treatment and outcome were recorded. RESULTS Ninety-five percent of patients were prescribed angiotensin-converting enzyme inhibitors and/or angiotensin-receptor blocker (ACEI/ARB) therapy, 78% statin therapy, 70% antiplatelets and 38% IS. The 5-year actuarial rates for PR, CR, RRT and death were 76.4, 24.4, 11.9 and 16.8%, respectively. In patients achieving at least one PR, the 5-year actuarial risk of relapse was 32.8%. Using multivariate survival analysis, achievement of remission was the factor most strongly associated with reduced risk of RRT or death. There was no significant difference in outcomes between patients who did or did not receive IS, although patients receiving IS had more severe disease. Contrary to published findings, 81.8% of patients treated with the Ponticelli regimen (6 months of alternating prednisolone and cyclophosphamide or chlorambucil) suffered significant treatment-related complications compared with 19% of patients prescribed the Cattran regimen (prolonged combined low-dose prednisolone and cyclosporine). CONCLUSIONS Using an approach of widespread ACEI/ARB treatment and targeted IS, 76% of patients can expect to have achieved at least one PR by 5 years. Achievement of remission is the factor most strongly associated with reduced risk of RRT and death. Treatment with IS is associated with significant treatment complications.
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YUAN JIANGZI, FANG WEI, ZHANG WEIMING, NI ZHAOHUI, QIAN JIAQI. Treatment of nephrotic idiopathic membranous nephropathy with monthly i.v. pulse cyclophosphamide and oral steroids: A single centre's retrospective study. Nephrology (Carlton) 2011; 16:440-5. [DOI: 10.1111/j.1440-1797.2010.01427.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hofstra JM, Wetzels JFM. Alkylating agents in membranous nephropathy: efficacy proven beyond doubt. Nephrol Dial Transplant 2010; 25:1760-6. [PMID: 20133280 DOI: 10.1093/ndt/gfq017] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Julia M Hofstra
- Department of Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Polanco N, Gutiérrez E, Covarsí A, Ariza F, Carreño A, Vigil A, Baltar J, Fernández-Fresnedo G, Martín C, Pons S, Lorenzo D, Bernis C, Arrizabalaga P, Fernández-Juárez G, Barrio V, Sierra M, Castellanos I, Espinosa M, Rivera F, Oliet A, Fernández-Vega F, Praga M. Spontaneous remission of nephrotic syndrome in idiopathic membranous nephropathy. J Am Soc Nephrol 2010; 21:697-704. [PMID: 20110379 DOI: 10.1681/asn.2009080861] [Citation(s) in RCA: 242] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Spontaneous remission is a well known characteristic of idiopathic membranous nephropathy, but contemporary studies describing predictors of remission and long-term outcomes are lacking. We conducted a retrospective, multicenter cohort study of 328 patients with nephrotic syndrome resulting from idiopathic membranous nephropathy that initially received conservative therapy. Spontaneous remission occurred in 104 (32%) patients: proteinuria progressively declined after diagnosis until remission of disease at 14.7 +/- 11.4 months. Although spontaneous remission was more frequent with lower levels of baseline proteinuria, it also frequently occurred in patients with massive proteinuria: 26% among those with baseline proteinuria 8 to 12 g/24 h and 22% among those with proteinuria >12 g/24 h. Baseline serum creatinine and proteinuria, treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists, and a >50% decline of proteinuria from baseline during the first year of follow-up were significant independent predictors for spontaneous remission. Only six patients (5.7%) experienced a relapse of nephrotic syndrome. The incidence of death and ESRD were significantly lower among patients with spontaneous remission. In conclusion, spontaneous remission is common among patients with nephrotic syndrome resulting from membranous nephropathy and carries a favorable long-term outcome with a low incidence of relapse. A decrease in proteinuria >50% from baseline during the first year predicts spontaneous remission.
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Abstract
Treatment of idiopathic membranous nephropathy is based on a 'symptomatic' therapy that includes ACE inhibitors or angiotensin II receptor antagonists, and on an 'aetiological' therapy aimed at modulating underlying immunological mechanisms. The role of the latter is still debated given the usually indolent course of disease; furthermore, traditional immunosuppressants would not have an impact on patient and renal survival according to a systematic review of literature. However, up to 40% of untreated patients eventually develop end-stage renal disease and remission of nephrotic syndrome protects patients from related life-threatening complications and is the strongest positive prognostic factor for long-term kidney function. Therefore, immunosuppressive therapy seems to be rational in high-risk patients with nephrotic syndrome or deteriorating renal function. This article outlines a possible role for each 'aetiological' therapy on the basis of available evidence in order to provide some practical recommendations. The first-line therapy is based on a 6-month regimen of alternating corticosteroids and an alkylating agent ('Ponticelli' regimen), whereas oral ciclosporin and intramuscular corticotrophin (adrenocorticotrophic hormone) are alternatives that provide comparable results in terms of remission of proteinuria, with a different adverse effect profile. New drugs are emerging as potential treatments, such as mycophenolate mofetil, tacrolimus, intravenous immunoglobulins and rituximab. Specific settings, such as chronic renal failure or elderly age, require a careful balance between benefits and toxicity of immunosuppression. The tailor-made use of this repertoire of drugs can provide a tool to achieve remission of proteinuria and modify the natural course of idiopathic membranous nephropathy.
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Affiliation(s)
- Marco Quaglia
- Department of Clinical and Experimental Medicine, Amedeo Avogadro University, Italy
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Hofstra JM, Branten AJW, Wirtz JJJM, Noordzij TC, du Buf-Vereijken PWG, Wetzels JFM. Early versus late start of immunosuppressive therapy in idiopathic membranous nephropathy: a randomized controlled trial. Nephrol Dial Transplant 2009; 25:129-36. [DOI: 10.1093/ndt/gfp390] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Akioka K, Okamoto M, Ushigome H, Nobori S, Suzuki T, Sakai K, Sakamoto S, Urasaki K, Yanagisawa A, Fukatsu A, Yoshimura N. A case of living-related renal transplant from the donor with membranous nephropathy. Clin Transplant 2009; 23 Suppl 20:62-6. [DOI: 10.1111/j.1399-0012.2009.00999.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Optimum treatment of idiopathic membranous nephropathy is both controversial and challenging. The most extensively studied and frequently used immunosuppressive regimens for this disease comprise alkylating agents plus corticosteroids or ciclosporin. All of these treatment options have inherent problems: they are not effective in all patients, partial-rather than complete-remissions are common, adverse effects are worrisome, and relapses after treatment cessation remain problematic. Alternative immunosuppressive agents have been tested in an effort to overcome these unresolved issues. This paper reviews the available evidence regarding both established and new agents for the treatment of patients with idiopathic membranous nephropathy, with an emphasis on the results of the most recent clinical trials.
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Eriguchi M, Oka H, Mizobuchi T, Kamimura T, Sugawara K, Harada A. Long-term outcomes of idiopathic membranous nephropathy in Japanese patients treated with low-dose cyclophosphamide and prednisolone. Nephrol Dial Transplant 2009; 24:3082-8. [PMID: 19465558 DOI: 10.1093/ndt/gfp251] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Treatment with cyclophosphamide and steroids for idiopathic membranous nephropathy (IMN) is effective in Caucasian patients, but the cumulative cyclophosphamide dosage exceeds 10 g and includes steroid pulse therapy. Adverse effects and difficulties with repeating treatment are major limitations. We studied the long-term outcomes of low-dose cyclophosphamide and prednisolone therapy in Japanese patients, who were thought to have relatively benign IMN compared with Caucasian patients. METHODS This is a prospective cohort study of 103 consecutive Japanese patients with IMN and nephrotic syndrome. Patients were treated with cyclophosphamide (50 mg/day for the first 3 months and 25 mg/day for the next 3 months) and prednisolone (30 mg/day for the first week and the dosage was gradually tapered to withdraw by 2 years). Additional therapies were allowed for initial treatment failure or relapse. RESULTS With a mean observation period of 8.5 years, 90 patients (87.4%) achieved proteinuria of <1 g/day and 78 (75.7%) achieved complete remission. A total of 27 patients did not respond to initial treatment and 30 patients had relapses after remission. Of these patients, 39 received additional therapies. At the last observation, 12 patients had developed renal insufficiency (S-Cr >1.5 mg/dL) but only 2 patients had reached renal death. Multivariate analysis revealed that the duration without remission was the strongest risk factor for renal prognosis. There were 14 deaths, and 8 patients developed cancers during the observation period. CONCLUSION Treating nephrotic IMN in Japanese patients with low-dose cyclophosphamide and prednisolone is beneficial for long-term renal prognosis with relatively few adverse effects.
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Membranous glomerulonephritis: treatment response and outcome in children. Pediatr Nephrol 2009; 24:301-8. [PMID: 18846392 DOI: 10.1007/s00467-008-1005-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Revised: 07/08/2008] [Accepted: 08/15/2008] [Indexed: 10/21/2022]
Abstract
The aim of this study was to characterize clinical features, treatment response, and outcome of idiopathic membranous glomerulonephritis (MGN) in a single-center cohort of children. A retrospective review of biopsy-proven idiopathic MGN in 12 children (mean age 11.9 years) was undertaken. Presentation was nephrotic syndrome (NS) (75%), hematuria/proteinuria (17%), and asymptomatic proteinuria (8%). Ten patients (83%) with NS and nephrotic range proteinuria (NRP) were treated with prednisone, and two patients with non-NRP were not treated with immunosuppressive medications. Steroid response in the treated patients was complete (10%), partial (40%), and absent (50%), respectively. Oral cyclophosphamide was used in seven patients of whom five were steroid resistant, one was steroid dependent, and one was partially responsive. At the mean follow up of 27 months, outcome parameters included an estimated glomerular filtration rate of 128 cc/min per 1.73 m(2), albumin of 4.2 gm/dL, and a urine protein/creatinine ratio of 0.87 [median 0.16 (range 0.02-6.52)]. Remission was complete in 75% of the patients and partial in 17%. One patient (8%) with chronic kidney disease (stage 2) was unresponsive to therapy. Complete remission was significantly associated with the absence of chronic histological changes (p = 0.03). In conclusion, children with NS and/or NRP associated with MGN appear to have a good prognosis when treated with a combination of corticosteroids and cyclophosphamide.
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&NA;. Symptomatic therapy is the cornerstone of membranous nephropathy treatment in the elderly, with immunosuppressive therapy reserved for high-risk patients. DRUGS & THERAPY PERSPECTIVES 2008. [DOI: 10.2165/00042310-200824080-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Hofstra JM, Wetzels JFM. Introduction of a cyclophosphamide-based treatment strategy and the risk of ESRD in patients with idiopathic membranous nephropathy: a nationwide survey in the Netherlands. Nephrol Dial Transplant 2008; 23:3534-8. [PMID: 18559961 DOI: 10.1093/ndt/gfn350] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The efficacy of immunosuppressive therapy in preventing ESRD in patients with idiopathic membranous nephropathy (iMN) is debated. From 1991 onwards, we have advocated a restrictive treatment strategy in our university hospital and regional referring hospitals. We advised the use of immunosuppressive therapy, consisting of a combination of steroids and oral cyclophosphamide for 12 months, in patients with iMN at high risk for ESRD. METHODS Primary renal diagnosis of all patients who start renal replacement therapy in the Netherlands is registered in the RENINE database. We studied the incidence of ESRD due to iMN in the Netherlands in the period 1991-2005. We mailed a questionnaire to all nephrology centres that entered a patient with ESRD and iMN in the RENINE database after 2000. RESULTS The introduction of the cyclophosphamide-based treatment strategy in the Nijmegen region resulted in a significant 70% reduction in the incidence of ESRD in patients with iMN as compared to an unchanged incidence in other parts of the Netherlands. The response rate to the questionnaire was 65%. There were 45 patients (34 M, 11 F) with a mean age of 49 +/- 17 years at diagnosis and a median serum creatinine of 138 micromol/l (range 60-1798). Overall, only 22 patients (49%) had been treated with immunosuppressive therapy, consisting of prednisone monotherapy in 7. CONCLUSIONS Our data suggest that the introduction of a cyclophosphamide-based restrictive treatment policy has reduced the risk of ESRD in iMN. The questionnaires reflect the differences in opinion on the optimal treatment of high-risk patients with iMN.
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Affiliation(s)
- Julia M Hofstra
- Department of Nephrology 464, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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Hofstra JM, Deegens JKJ, Willems HL, Wetzels JFM. Beta-2-microglobulin is superior to N-acetyl-beta-glucosaminidase in predicting prognosis in idiopathic membranous nephropathy. Nephrol Dial Transplant 2008; 23:2546-51. [DOI: 10.1093/ndt/gfn007] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Fervenza FC, Sethi S, Specks U. Idiopathic Membranous Nephropathy: Diagnosis and Treatment. Clin J Am Soc Nephrol 2008; 3:905-19. [PMID: 18235148 DOI: 10.2215/cjn.04321007] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, 200 First Street, SW, Rochester, MN 55905, USA.
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Ahmed MS, Hou SH, Battaglia MC, Picken MM, Leehey DJ. Treatment of Idiopathic Membranous Nephropathy With the Herb Astragalus membranaceus. Am J Kidney Dis 2007; 50:1028-32. [DOI: 10.1053/j.ajkd.2007.07.032] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 07/05/2007] [Indexed: 11/11/2022]
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Ruggenenti P, Cravedi P, Remuzzi G. Latest treatment strategies for membranous nephropathy. Expert Opin Pharmacother 2007; 8:3159-71. [DOI: 10.1517/14656566.8.18.3159] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Deegens JKJ, Wetzels JFM. Membranous nephropathy in the older adult: epidemiology, diagnosis and management. Drugs Aging 2007; 24:717-32. [PMID: 17727303 DOI: 10.2165/00002512-200724090-00002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Membranous nephropathy is the most important cause of the nephrotic syndrome in elderly patients (aged >65 years). The clinical presentation is similar in older and younger patients, although elderly patients more often present with renal failure. Notably, glomerular filtration rate (GFR) is usually lower in the elderly due to the physiological decline in GFR after the age of 30 years. Secondary causes, especially malignancies, are more common in older patients with membranous nephropathy. Therefore, elderly patients should undergo a thorough examination to exclude a secondary cause. The prognosis of elderly patients with idiopathic membranous nephropathy is not very different from that of younger patients. All elderly patients should receive symptomatic treatment aimed at reducing hypertension, oedema, proteinuria and hyperlipidaemia. It is recommended that elderly patients with a low serum albumin (<2 g/dL) receive prophylactic anticoagulation because of a high risk for thrombosis. Immunosuppressive therapy should be reserved for elderly patients at high risk of progression to end-stage renal disease because the elderly are particularly prone to the adverse effects and infectious complications of immunosuppressive therapy. High-risk elderly patients are characterised by renal insufficiency (GFR <45 mL/min/1.73m(2)), an increase in serum creatinine of >25% or a severe persistent nephrotic syndrome not responding to symptomatic treatment. In addition, elderly patients with a relatively normal GFR (>or=45 mL/min/1.73m(2)) and high urinary excretion of beta(2)-microglobulin and IgG are also at increased risk of developing end-stage renal disease; however, the deterioration in renal function is usually a slow process. Therefore, such patients benefit from immunosuppressive therapy only if their life expectancy is good. If immunosuppressive therapy is started, first-line treatment consists of prednisone and cyclophosphamide. If cyclophosphamide is contraindicated or fails to induce a remission, ciclosporin could be used. Treatment with ciclosporin should be limited to patients with a relatively normal renal function (GFR >60 mL/min/1.73m(2)) in view of its nephrotoxicity in patients with renal dysfunction.
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Affiliation(s)
- Jeroen K J Deegens
- Department of Nephrology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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Wetzels JFM. Cyclophosphamide plus steroids for membranous nephropathy with nephrotic syndrome: long-term outcomes. NATURE CLINICAL PRACTICE. NEPHROLOGY 2007; 3:534-5. [PMID: 17712328 DOI: 10.1038/ncpneph0586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Accepted: 07/17/2007] [Indexed: 05/16/2023]
Affiliation(s)
- Jack F M Wetzels
- Department of Nephrology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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Branten AJ, du Buf-Vereijken PW, Vervloet M, Wetzels JF. Mycophenolate mofetil in idiopathic membranous nephropathy: a clinical trial with comparison to a historic control group treated with cyclophosphamide. Am J Kidney Dis 2007; 50:248-56. [PMID: 17660026 DOI: 10.1053/j.ajkd.2007.05.015] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2007] [Accepted: 05/24/2007] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cyclophosphamide can decrease proteinuria and improve renal function in patients with idiopathic membranous nephropathy, but has a high risk of side effects. We studied whether mycophenolate mofetil (MMF) could be a reasonable alternative with fewer side effects. STUDY DESIGN Clinical trial with historic controls. SETTINGS & PARTICIPANTS 32 cases and 32 controls with idiopathic membranous nephropathy and renal insufficiency at multiple centers. For comparison, we selected matched historic controls treated with cyclophosphamide. INTERVENTION MMF, 1 g twice daily, for 12 months versus cyclophosphamide, 1.5 mg/kg/d, for 12 months. Both groups also received intermittent methylprednisolone and alternate-day prednisone. OUTCOMES & MEASUREMENTS Serum creatinine, proteinuria, and side effects during and after treatment. RESULTS Median follow-up was 23 months (range, 11 to 46 months). Median serum creatinine levels were 1.8 mg/dL (159 micromol/L) in both groups at baseline and 1.4 mg/dL (124 micromol/L) in the MMF group versus 1.3 mg/dL (115 micromol/L) in the cyclophosphamide group at 12 months (P = 0.4). Proteinuria values at baseline and 12 months were protein of 8.40 and 1.41 g/d in the MMF group versus 9.19 and 1.13 g/d in the cyclophosphamide group (P = 0.5 at 12 months), respectively. Cumulative incidences of remission of proteinuria at 12 months were 66% in the MMF group versus 72% in the cyclophosphamide group (P = 0.3). Five patients (16%) in the MMF group versus none in the cyclophosphamide group had disease that did not respond to therapy (P = 0.05). Twelve patients (38%) experienced a relapse and 9 patients (31%) were re-treated in the MMF group compared with 4 (13%) and 2 patients (6%) in the cyclophosphamide group (P < 0.01 and P = 0.024, respectively). Side effects occurred in 24 patients (75%) in the MMF group and 22 patients (69%) in the cyclophosphamide group (P = 0.6). LIMITATIONS Nonrandomized control group, short duration of follow-up. CONCLUSIONS A 12-month course of MMF decreased proteinuria and improved renal function in the majority of patients, but did not appear as effective or better tolerated than cyclophosphamide. Long-term data and randomized controlled trials are needed to ascertain the efficacy of MMF in patients with idiopathic membranous nephropathy.
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Affiliation(s)
- Amanda J Branten
- Department of Nephrology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
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Westhoff TH, van der Giet M. Tacrolimus in the treatment of idiopathic nephrotic syndrome. Expert Opin Investig Drugs 2007; 16:1099-110. [PMID: 17594193 DOI: 10.1517/13543784.16.7.1099] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The immunosuppressant tacrolimus (FK-506) is a calcineurin inhibitor with a widespread use for the prevention of graft rejection in transplantation medicine. Tacrolimus inhibits the activation of an essential transcription factor for the transcription of cytokine genes in T cells leading to a decreased production of cytokines such as IL-2 and IFN-gamma. As T-cell activation plays a crucial role in the pathogenesis of inflammatory glomerular diseases, there is an increasing number of reports on the use of tacrolimus in nephrotic syndrome. In idiopathic nephrotic syndrome, corticosteroid treatment constitutes the first-line therapy to achieve remission. In the case of steroid resistance or steroid dependence, alternative immunosuppressive strategies are needed. Cyclophosphamide and ciclosporin are well-established drugs in this condition. The present article reviews the pharmacodynamics, pharmacokinetics, safety and clinical efficacy of tacrolimus in steroid-resistant and steroid-dependent nephrotic syndrome.
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Affiliation(s)
- Timm H Westhoff
- Charité--Campus Benjamin Franklin, Centrum 10--Nephrology, Hindenburgdamm 30, Berlin, Germany.
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Abstract
The treatment of idiopathic membranous nephropathy is heavily debated because of wide variation in outcome. A rational treatment strategy is needed to appropriately administer conservative treatment to the low-risk group but immunosuppressive therapy to those with medium or high risk of renal deterioration. Currently, combinations of steroids with alkylating agents are best studied. Newer forms of immunosuppressive treatment are currently under study.
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Affiliation(s)
- K N Lai
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong.
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Jha V, Ganguli A, Saha TK, Kohli HS, Sud K, Gupta KL, Joshi K, Sakhuja V. A randomized, controlled trial of steroids and cyclophosphamide in adults with nephrotic syndrome caused by idiopathic membranous nephropathy. J Am Soc Nephrol 2007; 18:1899-904. [PMID: 17494881 DOI: 10.1681/asn.2007020166] [Citation(s) in RCA: 213] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Idiopathic membranous nephropathy (IMN) is the most common cause of nephrotic syndrome in adults. Universal consensus regarding the need for and the modality of therapy has not been formed because of a lack of controlled trials of sufficient size, quality, and duration. This study compared the effect of a 6-mo course of alternating prednisolone and cyclophosphamide with supportive treatment in adults with nephrotic syndrome caused by IMN on doubling of serum creatinine, development of ESRD, and quality of life in a randomized, controlled trial. Patients were followed up for 10 yr. Data were analyzed on an intention-to-treat basis. A total of 93 patients completed the study. Of the 47 patients who received the experimental protocol, 34 achieved remission (15 complete and 19 partial), compared with 16 (five complete, 11 partial) of 46 in the control group (P < 0.0001). The 10-yr dialysis-free survival was 89 and 65% (P = 0.016), and the likelihood of survival without death, dialysis, and doubling of serum creatinine were 79 and 44% (P = 0.0006) in the two groups. Treated patients exhibited significantly lower prevalence of edema, hypertension, hypoalbuminemia, hyperlipidemia that required therapy, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use, and better quality of life on follow-up. The incidence of infections was similar in the two groups. In conclusion, untreated IMN with nephrotic syndrome is associated with a high risk for deterioration of renal function. A 6-mo regimen of cyclophosphamide and steroids induces remissions in a high proportion, arrests progression of renal insufficiency, and improves quality of life.
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Affiliation(s)
- Vivekanand Jha
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012 India.
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Praga M, Barrio V, Juárez GF, Luño J. Tacrolimus monotherapy in membranous nephropathy: A randomized controlled trial. Kidney Int 2007; 71:924-30. [PMID: 17377504 DOI: 10.1038/sj.ki.5002215] [Citation(s) in RCA: 178] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Membranous nephropathy is a common cause of nephrotic syndrome in adults. Although some patients with membranous nephropathy achieve a spontaneous remission, renal function continues to deteriorate in others. We conducted a prospective randomized trial evaluating monotherapy with tacrolimus to achieve complete or partial remission in patients with biopsy-proven membranous nephropathy. Twenty-five patients received tacrolimus (0.05 mg/kg/day) over 12 months with a 6-month taper, whereas 23 patients were in the control group. The probability of remission in the treatment group was 58, 82, and 94% after 6, 12, and 18 months but only 10, 24, and 35%, respectively in the control group. The decrease in proteinuria was significantly greater in the treatment group. Notably, six patients in the control group and only one in the treatment group reached the secondary end point of a 50% increase in their serum creatinine. No patient in the tacrolimus group showed a relapse during the taper period. Nephrotic syndrome reappeared in almost half of the patients who were in remission by the 18th month after tacrolimus withdrawal. We conclude that tacrolimus is a very useful therapeutic option for patients with membranous nephropathy and preserved renal function. The majority of patients experienced remission with a significant reduction in the risk for deteriorating renal function.
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Affiliation(s)
- M Praga
- Servicio de Nefrología, Hospital 12 de Octubre, Madrid, Spain.
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