A controlled trial of cyclophosphamide in patients with membranous glomerulonephritis

Controversies in the treatment of idiopathic membranous nephropathy

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.

Medical decision-making in membranous nephropathy: how to use limited clinical research evidence in patient management

Evidence-based medicine (EBM) originally referred to the use of a combination of clinical expertise and research evidence to make medical decisions, while carefully considering the patient's preference. In Japan, however, EBM has been misunderstood as the more abstract pursuit of acquiring research evidence and building medical guidelines. This review aims to summarize the available data regarding therapy for membranous nephropathy (MN), a field in which no consensus has been reached, and to discuss medical decision-making by using a decision tree in several model cases. In clinical practice, we have to consider both the risks and benefits of treatment. These are evaluated by their therapeutic effect (the rate of improvement, no change, or worsening) and by the patients' quality of life (QOL). This process is compatible with the essential concept of EBM.

Unresolved issues and current concepts in management of primary glomerulonephritis

The successful treatment of primary glomerulonephritis (GN) presenting with nephrotic syndrome in adults depends heavily on an accurate diagnosis. A successful diagnosis depends on a correct approach, combining light microscopy, immunofluorescence, and other special staining of renal biopsy material examined by a trained nephropathologist. A good clinical history and serological tests easily rule out possible secondary causes (for example, infection, autoimmune, metabolic or toxic) in most cases. Unfortunately, these procedures are not put into practice in most cases in developing countries, resulting in missed diagnosis and unnecessary steroid and immunosuppressant therapy with its inherent morbidity. Following the emergence of IgA and IgM nephropathies as very common forms of glomerular disorders in some countries, immunofluorescence has become absolutely necessary for their diagnosis. Moreover, a recent meta-analysis has defined different treatment protocols for minimal change nephropathy, focal segmental glomerulosclerosis, membranous nephropathy, and IgA nephropathy for a better outcome. This article emphasizes and elaborates on these issues for proper management of primary GN.

Recent developments in the management of membranous nephropathy

Idiopathic membranous nephropathy is one of the most commonly encountered forms of nephrotic syndrome in adults. The natural history of the disease, observed in a small sample of untreated patients, reveals that a large proportion of patients experience spontaneous remission, whereas approximately one third of them progress towards renal insufficiency, and thus require dialysis. Hence, several attempts to treat this condition have been investigated and several protocols, based on different combinations of corticosteroids and/or immunosuppressive agents, have been proposed. However, none of these protocols has been uniformly adopted by renal physicians, either because of no or limited efficacy of most of them, or due to the potential of short- and long-term untoward effects. In this review, we examine the available data on the natural course of the disease and the possibility of identifying clinical and laboratory characteristics that could help to predict the course of membranous nephropathy. We also summarise the results of the most relevant clinical trials, and offer an updated meta-analysis of treatment studies, including the latest data on cyclosporin.

Developments in the Immunotherapy of Glomerular Disease

Glomerular diseases span a broad spectrum of clinical syndromes, with varied clinical manifestations, underlying etiologies, and pathogenic mechanisms. They can be secondary to underlying infectious, toxic, environmental, or drug exposures, or present as “primary entities.” In the latter case, most glomerular diseases are thought to be due to autoimmune dysregulation, and their treatment is primarily immunosuppressive. The armamentarium for immunomodulation includes corticosteroids, alkylating agents, anti-metabolites, calcineurin inhibitors, and new biological agents designed to block specific inflammatory pathways. The choice of therapy for an individual patient must be based on the specific character of the glomerular disease and its acuity and severity, as well as the patient’s comorbidities, history of prior exposure to immunosuppressive drugs, and risk factors for developing complications of the disease or its treatment. The complexities of such therapy can best be addressed by an experienced team of care givers in which the clinical pharmacist can help minimize, if not eliminate, potential sources of drug induced toxicities and adverse effects. This article will describe the major agents and modalities used in the management of the most common glomerular diseases.

Treatment of idiopathic membranous nephropathy (IMN)

The best treatment of idiopathic membranous nephropathy remains an area of clinical controversy. At the moment only patients with nephrotic syndrome and/or declining renal function should be treated. Despite the negative trials, prolonged oral administration of corticosteroids alone may be a safe and an effective first-line treatment in nephrotic patients. If corticosteroids are ineffective, prolonged use of cyclosporine in low-doses can be recommended as an alternative treatment, that diminishes rapidly proteinuria in the majority of patients. Both treatments (intravenous high doses of corticosteroids and cyclosporine) may also be effective in patients with declining renal function. Because of their toxicity, the routine use of alkylating agents for patients with nephrotic syndrome is not justified. They may be retained for patients, in whom other treatment modalities have failed. Chlorambucil may be preferred over cyclophosphamide since it carries less toxicity. A lower dose of chlorambucil, than that usually suggested, for a short period of time seems to be prudent in an effort to avoid serious side-effects.

Does immunosuppression with prednisolone and azathioprine alter the progression of idiopathic membranous nephropathy?

The role of immunosuppressive drugs in the treatment of idiopathic membranous nephropathy (IMN) remains controversial. The effect of treatment with prednisolone and azathioprine in patients with nephrotic-range proteinuria and biopsy-proven IMN from a single center (Sheffield Kidney Institute, Sheffield, UK) is described. In this retrospective study, 58 patients with IMN and nephrotic-range proteinuria were followed up for 4 years. Thirty-eight patients were treated with prednisolone (1 mg/kg body weight/d) and azathioprine (2 mg/kg body weight/d) orally for a median period of 26 months (range, 6 to 48 months). Twenty patients received no specific treatment for IMN and served as a control group. Clinical, biochemical, and histopathologic features at presentation were similar between the groups. Renal function (RF), measured by serum creatinine (Scr) level, deteriorated in both treated and control groups during the follow-up period. The median initial and final Scr levels (at the end of follow-up) in the treated group were 1.6 and 2. 1 mg/dL, respectively, and in the control group were 1.3 and 1.7 m/dL, respectively (P = not significant). Neither the rate of RF decline (measured by the slope of reciprocal of Scr against time) nor the proportion of patients with deteriorating RF differed significantly between the groups (37%, treated group; 30%, control group). A significant reduction in proteinuria was observed in both groups (P < 0.01, either group). Also, the rate of remission of nephrotic-range proteinuria was not significantly different between groups (55%, treated group; 65%, control group). The only prognostic factor that correlated with RF outcome (expressed by final Scr level) in a given patient was the mean proteinuria during follow-up in either group (r = 0.493; P < 0.01, treated group; r = 0.651; P < 0.01, control group). Adverse effects of immunosuppressive treatment were observed in nine patients (24%). These were serious in four patients (10%) and included squamous cell carcinoma (two patients), bacterial meningitis (one patient), and septicemia (one patient). In conclusion, treatment with prednisolone and azathioprine for patients with IMN did not show significant beneficial effects on the progression of disease. Furthermore, this treatment was associated with frequent and serious adverse effects.

Management of idiopathic membranous nephropathy: evidence-based recommendations

Membranous nephropathy is a frequent cause of nephrotic syndrome in adults, and in one third of these patients, it leads to end-stage renal disease. Based on an extensive critical review of the literature, the following recommendations are offered. Oral high-dose corticosteroids are ineffective in producing either a sustained remission of nephrotic syndrome or in preserving renal function in patients with membranous nephropathy, and should not be used as the sole therapy (grade A recommendation). The use of azathioprine is not associated with any significant benefits, so its use is not justified (grade C). The alkylating agents cyclophosphamide and chlorambucil are both effective in the management of membranous nephropathy. Because of growing concern about long-term toxicity, especially with cyclophosphamide, these drugs should be reserved for patients who exhibit clinical features, such as severe or prolonged nephrosis, renal insufficiency, or hypertension, that predict a high likelihood of progression to end-stage renal disease. Chlorambucil in conjunction with oral steroids is the drug of first choice (grade A). Cyclophosphamide and oral steroids are alternatives (grade B). Cyclosporine may, in the future, become the agent of choice for membranous nephropathy. Currently, it is recommended (grade B) that cyclosporine use be considered in patients at high risk for progression in membranous nephropathy or if alkylating agents are contraindicated or ineffective.

Diagnosis and management of glomerular diseases

Glomerular diseases are a diagnostic challenge. Early recognition and timely institution of appropriate treatment are critical to optimum outcome in many patients, especially those with rapidly progressive glomerulonephritis. The clinical presentations and laboratory data provide adequate presumptive diagnoses in some patients; however, renal biopsy evaluation is often required for a definitive diagnosis.

The primary glomerulopathies

Disorders of glomerular structure and function are encountered frequently in clinical medicine. Many arise as part of a well-defined multisystem or multi-organ disease process, while in others the clinical and laboratory manifestations are consequent to the sole or predominant involvement of glomeruli. The latter are known as the primary glomerulopathies. These disorders can evoke a variety of clinical syndromes, including acute glomerulonephritis, rapidly progressive glomerulo-nephritis, nephrotic syndrome, "symptomless" hematuria and/or proteinuria, and chronic glomerulonephritis. The identification of underlying morphology, through the application of renal biopsy techniques, can provide useful information for both prognosis and treatment. Pathogenic mechanisms involved in the primary glomerulopathies are varied, but immunologic perturbations underlie many disease entities. This article describes the clinical features, pathology, natural history, and treatment of the main categories of primary glomerulonephritis, with emphasis on recent developments and practical aspects of diagnosis and management.

Urinary C5b-9 excretion and clinical course in idiopathic human membranous nephropathy

Recent reports suggested that the presence of terminal complement complex (C5b-9) in urine from patients with idiopathic membranous nephropathy (IMN) may indicate on-going immunological damage. This report documents the relationship between C5b-9 excretion and clinical outcome in 35 adult patients with biopsy-proven IMN and progressively declining renal function. There were two groups of patients. Group I received one of three treatment regimens: prednisolone alone, prednisolone and chlorambucil, or prednisolone and cyclophosphamide (N = 22). Group II received no immunosuppressive therapy (N = 17). Three of the 18 patients receiving immunosuppressive drugs had more than one treatment regimen as they experienced a clinical relapse during the study period; hence 22 treatments were available for analysis. Urine samples were collected regularly and urinary C5b-9 (uC5b-9) was determined by ELISA. Both groups were similar with respect to age, sex distribution, and the duration of follow-up. An improvement in proteinuria and creatinine clearance was noted in the immunosuppressed group. Thirty-five patients were excreting C5b-9 initially (18 from group I and 17 from group II); 17 patients continued to excrete C5b-9 at the end of the observation period. These 17 patients had a significantly worse clinical outcome when compared to the 18 patients whose C5b-9 excretion became negative, either spontaneously or with treatment (P < 0.005). These results indicate that continuing C5b-9 excretion is correlated with a poor clinical outcome. They also suggest that uC5b-9 is a dynamic marker of ongoing immunological injury, and therefore may be useful in the initial assessment and monitoring of patients with IMN and in identifying patients who may derive benefit from immunosuppressive therapy.

A review of therapeutic studies of idiopathic membranous glomerulopathy

The treatment of idiopathic membranous glomerulopathy remains an enigma. We have reviewed many of the important clinical trials concerning membranous glomerulopathy using a meta-analysis and a secondary pooled analysis to test the effects of corticosteroid or alkylating, therapy compared with no treatment on renal survival and complete remission of the nephrotic syndrome. A search was performed using MEDLINE (1968 through 1993) for articles on idiopathic membranous glomerulopathy and glomerulonephritis. Bibliographies of articles were reviewed for completeness. Sixty-nine articles were reviewed. Meta-analysis was performed for four trials that evaluated corticosteroids compared with no treatment and for three trials that evaluated alkylating therapy compared with no treatment. Pooled analysis was performed on randomized and prospective studies (10 studies) and then with 22 case series added. All studies evaluated renal biopsy-proven disease. Meta-analysis was performed on the relative chance of being in complete remission for each study. Renal survival could be evaluated by pooled analysis only. For pooled analyses, Cox's proportional hazard and logistic regression models were used to test the effect of therapy on renal survival and the nephrotic syndrome, respectively. Data concerning gender, nephrotic syndrome, and geographic region were used in all statistical models. Evaluation of renal survival revealed no differences by treatment group (P > 0.1). By meta-analysis, the relative chance of complete remission was not improved for corticosteroid-treated patients (1.55; 95% confidence interval, 0.99 to 2.44; P > 0.1), but was improved for patients treated with alkylating agents (4.8; 95% confidence interval, 1.44 to 15.96; P < 0.05) when compared with no treatment. Pooled analysis of randomized and prospective studies, as well pooled analysis with all studies, supported the findings of the meta-analysis. Corticosteroids or alkylating therapy did not improve renal survival in idiopathic membranous glomerulopathy. Complete remission of the nephrotic syndrome was observed more frequently with the use of alkylating agents.

A controlled trial of cyclosporine in patients with progressive membranous nephropathy. Canadian Glomerulonephritis Study Group

A controlled trial of cyclosporine in patients diagnosed with progressive membranous nephropathy (MGN) was carried out to determine whether cyclosporine (D) would be more effective than placebo (P) in reducing the rate of deterioration in renal function. Patients (N = 64) with MGN were placed on a restricted protein diet (< or = 0.9 g/kg) and followed closely for 12 months (Part 1). Patients at high risk of progression based on an absolute loss in creatinine clearance (CCr) of > or = 8 ml/min and persistent nephrotic range proteinuria (Pr) were selected and randomly assigned to either (D) (N = 9) or (P) (N = 8) for 12 months (Part 2). No differences in the two groups were noted at entry. After 12 months, the improvement in CCr slope in ml/min/month was significantly greater in the D patients (D + 2.1 vs. P + 0.5, mean difference 1.6; 95% CI 0.3 to 3.0, P < 0.02). This improvement was maintained in six of eight D (75%) over a mean follow-up period of 21 months. Daily Pr also improved with D (by month 3, D - 4.5 g/day vs. P + 0.7 g/day, P = 0.02) and was sustained in six of eight (75%) D patients. When Pr was expressed as a function of their concurrent CCr, the D versus P patients' time to halving was faster (P = 0.02) and absolute number higher (4/9 D vs 0/8 P). In the D group a trend towards worse hypertension and an increase in the number of transient rises in serum creatinine were noted.(ABSTRACT TRUNCATED AT 250 WORDS)

Fundamental concepts and immunosuppressive treatment in the various forms of glomerulonephritis

Immunosuppressive treatment in glomerulonephritis (GN) is still controversial. Most of the secondary forms of glomerulonephritis have the histologic features of one of the primary types of glomerulonephritis. Eight histologic expressions of primary glomerulonephritis can be distinguished and ordered in terms of severity of symptoms and prognosis: endocapillary GN, minimal change GN, mesangioproliferative GN, membranous GN, focal-sclerosing GN, membranoproliferative GN, focal-necrotizing GN, and rapidly progressive GN. Agreement exists only to the extent that immunosuppression is not required in endocapillary glomerulonephritis, although it is recommended in the other extreme of rapidly progressive GN. Primarily, an indication for immunosuppression is given by the severity of symptoms with a urinary protein excretion > 3.5 g per day and/or serum creatinine > 150 mumol per liter. As for anti-GBM, the type of glomerulonephritis is more important than the severity of symptoms in guiding therapy, whereas for IgA nephropathy it is controversial whether the prospective prognosis of even inexorably deteriorating renal function justifies immunosuppression. Renal biopsy is required to identify the type of glomerulonephritis so as to establish the specific immunosuppressive concept with different intensity and duration of treatment. Immunosuppression can reduce urinary protein excretion and improve deterioration of renal function; however, the proportion of patients responding varies with and depends on the different forms of GN.

Therapy for idiopathic membranous nephropathy: tailoring the choice by decision analysis

Two Italian controlled trials demonstrated that the difference in remission rates obtained with six months of methylprednisolone and chlorambucil (MP+Ch) compared to MP was smaller than MP+Ch versus symptomatic therapy in the treatment of idiopathic membranous nephropathy nephrotic syndrome (NS). A decision analysis was used to compare the three treatment strategies, assuming triple probabilities and costs for MP+Ch complications compared to MP, with no risk for supportive therapy, referring to an average 40-year-old patient and using the quality-adjusted life expectancy year (QALY) as the utility scale. With MP+Ch the difference in expected QALY was 7.2 years compared to supportive therapy, and 2.6 years compared to MP. To offset the longer survival obtained with MP+Ch versus MP, it was assumed that all patients treated with MP+Ch would undergo either fatal (5% vs. 0.3% with MP) or non-fatal complications (95% vs. 15% with MP). This threshold denotes a great stability of the inequality in the expected QALY. Consequently, treatment with MP or with MP+Ch is justified if their side effects are considered to be a suitable trade-off for a five or seven QALY, respectively, longer survival. Only an absurd increase in the death rate with MP+Ch could offset the difference.

Prognosis of untreated patients with idiopathic membranous nephropathy

BACKGROUND

Defining the most appropriate treatment for patients with idiopathic membranous nephropathy is a matter of controversy. The course of the disorder is often benign, and the immunosuppressive regimens used in some patients have uncertain benefits and substantial risks. We studied the natural history of idiopathic membranous nephropathy in patients who received only symptomatic therapy.

METHODS

We prospectively studied 100 consecutive patients (68 men and 32 women; mean [+/- SD] age, 51 +/- 17 years) with biopsy-proved idiopathic membranous nephropathy. The patients received diuretic or antihypertensive drugs as needed, but no glucocorticoid or immunosuppressive drugs. We examined the patients and measured their urinary protein excretion and serum creatinine concentrations every 6 months for a mean of 52 months.

RESULTS

Twenty-four (65 percent) of the 37 patients followed for at least five years had complete or partial remission of proteinuria; in 6 others (16 percent), end-stage renal disease developed, and they required dialysis. As calculated by the Kaplan-Meier method, the estimated probability (+/- the standard error of the estimate) of retaining adequate kidney function was 88 +/- 5 percent after five years and 73 +/- 7 percent after eight years. The prognosis was poorer in men and in patients over 50 years of age, but not in patients with the nephrotic syndrome, hypertension, or hypercholesterolemia.

CONCLUSIONS

Most untreated patients with idiopathic membranous nephropathy maintain renal function for prolonged periods and are likely to have spontaneous remission. These results do not support the use of glucocorticoids and immunosuppressive drugs in patients with idiopathic membranous nephropathy.

Cyclophosphamide provides no additional benefit to steroid therapy in the treatment of idiopathic membranous nephropathy

Thirty-six patients with idiopathic membranous nephropathy were retrospectively studied. The mean age was 47 years and the male to female ratio 25 to 11. Twenty-eight patients (77.8%) had nephrotic syndrome at first investigation. Nineteen patients received corticosteroids alone (group A) and 17 received corticosteroids combined with cyclophosphamide (group B). The mean period of follow-up was 58.9 months (range, 12 to 156 months). The two groups did not differ in clinical or laboratory features at the time of biopsy or at the start of treatment. In the entire series a complete remission of proteinuria occurred in 13 of 36 patients (36.1%) and a partial remission occurred in 13 (36.1%); 10 patients (27.8%) had no response. Optimal remission of proteinuria was usually recorded 6 to 12 months after the start of treatment. The two groups showed no statistical differences regarding the rate of complete (seven v six patients; P = not significant) or partial (six v seven patients; P = not significant) remissions. Two patients (one from each group) entered end stage renal failure during follow-up. At last assessment, the number of patients with complete remission (four v three patients; P = not significant), nonnephrotic proteinuria (nine v nine patients; P = not significant), or nephrotic syndrome (five v four patients; P = not significant) was similar in both groups. In addition, final plasma creatinine did not differ significantly between the two groups (1.8 +/- 2.3 mg/dL v 2.6 +/- 2.6 mg/dL; P = not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Methylprednisolone plus chlorambucil as compared with methylprednisolone alone for the treatment of idiopathic membranous nephropathy. The Italian Idiopathic Membranous Nephropathy Treatment Study Group

BACKGROUND AND METHODS

Treatment with methylprednisolone and chlorambucil may protect renal function and increase the chance of remission of the nephrotic syndrome in patients with idiopathic membranous nephropathy. To determine whether similar results might be obtained with methylprednisolone alone, we compared the effects of methylprednisolone and chlorambucil with those of methylprednisolone alone in 92 patients with the nephrotic syndrome caused by idiopathic membranous nephropathy. The patients were randomly assigned to receive either alternating one-month courses of methylprednisolone and then chlorambucil for a total of six months (group 1) or methylprednisolone alone for six months at the same cumulative dosage (group 2).

RESULTS

Four of the 45 patients in group 1 (9 percent) and 1 of the 47 in group 2 (2 percent) stopped treatment because of side effects. At one, two, and three years, the percentage of patients who did not have the nephrotic syndrome was significantly higher in group 1 than in group 2. It was 58, 54, and 66 percent, respectively, in group 1, as compared with 26, 32, and 40 percent in group 2 (P = 0.002, 0.029, and 0.011). By year 4, the difference was no longer statistically significant: 62 percent of the patients in group 1 and 42 percent of those in group 2 did not have the nephrotic syndrome (P = 0.102). The patients in group 1 were in remission longer than those in group 2 (P = 0.008).

CONCLUSIONS

In patients with the nephrotic syndrome caused by idiopathic membranous nephropathy, treatment with methylprednisolone and chlorambucil for six months induces an earlier remission of the nephrotic syndrome than methylprednisolone alone, but the difference may diminish with time.

Long-term benefits of therapy with cyclophosphamide and prednisone in patients with membranous glomerulonephritis and impaired renal function

Long-term follow-up data are provided for a previously reported study of patients with membranous glomerulonephritis (MGN), nephrotic syndrome, and renal function impairment. Nine patients were treated with cyclophosphamide (1 to 2 mg/kg) and six of these received concurrent prednisone; they are compared with 17 concurrent controls (14 of whom had received prednisone at some time). The mean follow-up is 83 +/- 13 months in the treated patients and 64 +/- 7 months in the controls. Of the nine treated patients, four achieved a complete remission from the nephrotic syndrome (proteinuria less than 0.5 g/d), and five a partial remission (proteinuria decreased by at least 50% and to less than 3.5 g/d). One of the nine treated patients and 10 of the 17 controls have reached end-stage renal disease (ESRD) (P less than 0.05). Nine of the controls reaching ESRD had persistent nephrotic syndrome, whereas of the seven controls who have not yet reached ESRD, only two have persistent nephrotic syndrome (chi 2, P less than 0.02). There have been four relapses in three treated patients, and three of the four have responded to repeat therapy. One patient refused full therapy and remains nephrotic. Life-table analysis demonstrates significantly increased survival from ESRD in treated patients as compared with controls (P = 0.04).

Measurement of SC5b-9 in urine in patients with the nephrotic syndrome

In passive or active Heymann nephritis (HN) in the rat, the immune complexes that form in the glomerular subepithelial space result in complement activation and the urinary (U) excretion of S protein-membrane attack complex (SC5b-9, MAC). Because of the similarities between HN in rats and membranous nephropathy (MN) in humans, it has been suggested that measurement of SC5b-9 in urine (UMAC) could be useful in assessing the immunologic activity of MN in patients. The present study was undertaken in normal individuals and in patients with nephrotic syndrome to determine: 1) the conditions of urine collection and preservation needed for accurate measurement of UMAC for clinical purposes; and 2) whether UMAC levels are a sensitive and/or specific test for MN. In studies conducted on urine specimens from patients with increased UMAC levels, we found that UMAC in freshly voided urine was stable for at least three hours at 37 degrees C, with or without the addition of the enzyme inhibitors that were used to stabilize UMAC levels in the studies of HN in the rat. Urine pH, leukocytes and erythrocytes, over the ranges usually encountered, did not influence UMAC levels. However, freezing urine at -70 degrees C artifactually raised UMAC levels (1500 +/- 550 to 1800 +/- 580 SE ng/ml, P less than 0.001 by paired t-test). Normal urine contained low UMAC levels: 80 +/- 3 ng/mg urinary creatinine (UCr). By contrast, patients with glomerulopathies tended to have elevated UMAC levels: 18 of 38 patients had levels that ranged from 200 to 20,000 ng/mg UCr.(ABSTRACT TRUNCATED AT 250 WORDS)

Crescentic transformation in primary membranous glomerulonephritis

A 31 year old man first developed steroid-resistant idiopathic membranous glomerulonephritis in 1981. Stable normal renal function was maintained until August 1988 when he suffered a clinical relapse with heavy proteinuria and declining renal function. Immunosuppressive therapy with prednisolone and cyclophosphamide was instituted in an attempt to arrest this relapse. Despite this, he later developed acute renal failure with histological evidence of crescentic transformation of his nephritis. This unusual transformation was not associated with features of systemic vasculitis or positive anti-glomerular basement membrane and anti-neutrophil cytoplasmic antibodies.

Membranous nephropathy in childhood and its treatment

Membranous nephropathy is predominantly a disease of middle-aged and elderly individuals, and is thus rather an uncommon finding in proteinuric and nephrotic children. In children, it differs in several important respects from the disease as seen in adults: an apparent associated cause is more common, macroscopic haematuria is seen quite frequently, a relapsing course is more often noted, renal venous thrombosis is not found and evolution into renal failure is the exception. Nevertheless, a proportion of children with membranous nephropathy do evolve into renal failure, and their management is discussed with particular reference to recent papers on the treatment of membranous nephropathy in adults. An aggressive search for associated disease is worthwhile in children, and one should wait to see what the evolution or proteinuria and renal function may be. If a progressive course becomes evident, then a trial of treatment with corticosteroids is worthwhile, but if this is ineffective then a more aggressive approach involving the use of alkylating agents may be justified. It remains undetermined what the best regime in children and adolescents may be.

A randomized trial of methylprednisolone and chlorambucil in idiopathic membranous nephropathy

We conducted a controlled trial to investigate the long-term effects of treatment with methylprednisolone and chlorambucil in patients with idiopathic membranous nephropathy. We have previously reported that after a mean of 31 months, treated patients did better. We now report the results of a longer follow-up. Eighty-one patients with proteinuria (greater than or equal to 3.5 g per day) and biopsy-proved membranous nephropathy were randomly assigned to receive either supportive therapy alone or a six-month course of corticosteroids alternated with chlorambucil (0.2 mg per kilogram of body weight per day) every other month. Methylprednisolone was first given intravenously in three pulses (1 g per day) and was then given orally (0.4 mg per kilogram per day) for 27 days. The patients were followed for 2 to 11 years (median, 5). Two patients in the control group and one in the treatment group died. At the last follow-up visit, 9 of 39 patients assigned to the control group (23 percent) and 28 of 42 patients assigned to the treatment group (67 percent) did not have the nephrotic syndrome. At five years there were more remissions of the nephrotic syndrome in treated patients than in controls (22 of 30 vs. 10 of 25; P = 0.026). Compared with base-line values, the mean reciprocal of the plasma creatinine level declined significantly in the control group (33 percent; P = 0.0002) but not in the treatment group (6 percent; P not significant). Plasma creatinine increased by 50 percent or more in 19 controls (49 percent) and in 4 treated patients (10 percent). We conclude that a six-month course of methylprednisolone and chlorambucil can bring about sustained remission of the nephrotic syndrome and help to preserve renal function in patients with idiopathic membranous nephropathy.

Prednisolone and chlorambucil treatment in idiopathic membranous nephropathy with deteriorating renal function

Eight patients with idiopathic membranous nephropathy whose renal function was deteriorating were given a 6-month course of alternating monthly cycles of prednisolone and chlorambucil. Proteinuria was reduced in all eight, from a mean (SD) of 15.3 (5.9) g/24 h at the start of treatment to 2.1 (1.5) g/24 h at follow-up (p less than 0.05). Creatinine clearance increased in six, and the rate of decline was reduced in the other two (group mean 51.6 [17.8] ml/min at the start of treatment and 81.4 [36.8] ml/min at follow-up; p less than 0.05). Adverse effects of chlorambucil were severe, and the daily dose had to be reduced. Prednisolone and chlorambucil treatment can change the natural course of membranous nephropathy even when renal function has started to deteriorate, so treatment can be reserved for high-risk patients.