Effectiveness and safety of cyclophosphamide or tacrolimus therapy for idiopathic membranous nephropathy

Efficacy of tacrolimus monotherapy in primary membranous nephropathy

Objective

The aim of this study was to observe the remission of primary membranous nephropathy (PMN) and evaluate the efficacy of tacrolimus (TAC) monotherapy for PMN in comparison with TAC combined with a low-dose glucocorticoid (GC) protocol (TAC + GC).

Methods

This was tested in a prospective monocentric observational trial of 70 patients with PMN, of whom 34 received TAC (0.05-0.075 mg/kg/day) or 36 received TAC (0.05-0.075 mg/kg/day) and GC (0.3-0.5 mg/kg/day of prednisone).

Results

At 3, 6, 9, and 12 months of treatment, the effective rates in the TAC group and the TAC + GC group were similar (P > 0.05). The urinary protein quantification was reduced in patients under both therapeutic protocols, and the differences in the proteinuria quantification at 3, 6, 9, and 12 months of treatment were not statistically significant between the two groups (P > 0.05). The overall incidence of adverse reactions in the TAC group was lower than that in the TAC + GC group (23.5% < 36.1%), and the difference was statistically significant (P < 0.05).

Conclusion

TAC monotherapy for PMN could effectively reduce urinary protein quantification and increase serum albumin levels. Compared with TAC + GC, TAC monotherapy for PMN had no difference in efficacy and fewer incidences of adverse reactions.

Comparative analysis of the efficacy of different treatments for idiopathic membranous nephropathy: a retrospectively real-world study

BACKGROUND

This study aimed to explore the clinical efficacy of different treatment regimens for idiopathic membranous nephropathy (IMN).

METHODS

Patients with IMN were retrospectively analyzed by dividing into two groups: glucocorticoids combined with cyclophosphamide group (GC + CYC) and glucocorticoids combined with calcineurin inhibitor group (GC + CNIs). After 1 year of treatment, those who found that the initial treatment was not effective were switched to another regimen. Patients continued to be followed up for at least 1 year to observe the treatment effects of different treatment regimens.

RESULTS

This study found that the rate of complete and partial remission (CR + PR) in the GC + CYC and GC + CNIs groups was 76.19 vs. 82.63% after 1 year of follow-up (p > .05). In the GC + CYC and GC + CNIs groups, 27.78 and 11.95% of the patients switched treatment regimens, respectively. After 2 years of follow-up, the CR + PR rate was significantly higher in the change to GC + CNIs group after the switch compared to before the switch (80.00 vs. 31.43%, p < .001). It was also significantly higher in the change to GC + CYC group compared to before the switch (68.42 vs. 31.58%, p = .023). The recurrence rate was significantly higher in the maintain GC + CNIs and change to GC + CNIs groups than in the maintain GC + CYC and change to GC + CYC groups (25.14 vs 6.36%, p < .001). The disengagement rate from immunotherapy was significantly higher in the maintain GC + CYC group and the change to GC + CYC group than in the maintain GC + CNIs group and the change to GC + CNIs group (76.36% vs 29.71%, p < .001). High titer of anti-phospholipase A2 receptor (anti-PLA2R) antibody (95%CI: 0.199-0.947, p = .036) and serum C3 (95%CI: 0.030-0.570, p = .007) were independent risk factors, while serum IgG (95%CI: 1.000-1.331, p = .050) was a favorable factor for achieving CR. Anti-PLA2R antibody was the independent risk factor that affected the worse renal condition (p = .023).

CONCLUSIONS

Timely change of treatment regimen can significantly enhance therapeutic effect. Compared with patients administered with CYC, those administered with CNIs were less likely to leave treatment and had a higher recurrence rate.

Epidemiology and Outcomes of Glomerular Diseases in Low- and Middle-Income Countries

Glomerular diseases account for a significant proportion of chronic kidney disease in low-income and middle-income countries (LMICs). The epidemiology of glomerulonephritis is characterized inadequately in LMICs, largely owing to unavailable nephropathology services or uncertainty of the safety of the kidney biopsy procedure. In contrast to high-income countries where IgA nephropathy is the dominant primary glomerular disease, focal segmental glomerulosclerosis is common in large populations across Latin America, Africa, Middle East, and South East Asia, while IgA nephropathy is common in Chinese populations. Despite having a high prevalence of known genetic and viral risk factors that trigger focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis also is common in adults and children in some African countries. Treatment of glomerular diseases in adults and children in LMICs largely is dependent on corticosteroids in combination with other immunosuppressive therapy, which often is cyclophosphamide because of its ready availability and low cost of treatment, despite significant adverse effects. Partial and/or complete remission status reported from studies of glomerular disease subtypes vary across LMIC regions, with high rates of kidney failure, mortality, and disease, and treatment complications often reported. Improving the availability of nephropathology services and ensuring availability of specific therapies are key measures to improving glomerular disease outcomes in LMICs.

Recent Advances in Clinical Diagnosis and Pharmacotherapy Options of Membranous Nephropathy

Membranous nephropathy (MN) is the most common cause of nephrotic syndrome among adults, which is the leading glomerular disease that recurs after kidney transplantation. Treatment for MN remained controversial and challenging, partly owing to absence of sensitive and specific biomarkers and effective therapy for prediction and diagnosis of disease activity. MN starts with the formation and deposition of circulating immune complexes on the outer area in the glomerular basement membrane, leading to complement activation. The identification of autoantibodies against the phospholipase A₂ receptor (PLA₂R) and thrombospondin type-1 domain-containing protein 7A (THSD7A) antigens illuminated a distinct pathophysiological rationale for MN treatments. Nowadays, detection of serum anti-PLA₂R antibodies and deposited glomerular PLA₂R antigen can be routinely applied to MN. Anti-PLA₂R antibodies exhibited much high specificity and sensitivity. Measurement of PLA₂R in immune complex deposition allows for the diagnosis of PLA₂R-associated MN in patients with renal biopsies. In the review, we critically summarized newer diagnosis biomarkers including PLA₂R and THSD7A tests and novel promising therapies by using traditional Chinese medicines such as Astragalus membranaceus, Tripterygium wilfordii, and Astragaloside IV for the treatment of MN patients. We also described unresolved questions and future challenges to reveal the diagnosis and treatments of MN. These unprecedented breakthroughs were quickly translated to clinical diagnosis and management. Considerable advances of detection methods played a critical role in diagnosis and monitoring of treatment.

Comparison of cyclophosphamide and calcineurin inhibitors for idiopathic membranous nephropathy: A protocol for systematic review and meta-analysis

BACKGROUND

Idiopathic membranous nephropathy (IMN) is one of the leading causes of nephrotic syndrome in adults. We performed a protocol for systematic review and meta-analysis to compare the efficacy and safety of cyclophosphamide (CTX) with calcineurin inhibitors (CNIs) in the treatment of IMN.

METHODS

PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and 3 Chinese databases (WanFang Data, Chongqing VIP and China National Knowledge Infrastructure) were searched from inception through January 2022 to identify randomized controlled trials that compared CTX with CNIs for patients with IMN. Systematic review and meta-analysis of the data will be performed in RevMan software (version 5.3) according to the preferred reporting items of systematic reviews and meta-analysis guidelines. Two authors independently performed the literature searching, data extraction, and quality evaluation. Risk of bias was assessed using the Cochrane Risk of Bias Tool for randomized controlled trials.

RESULTS

The results will be submitted to a peer-reviewed journal once completed.

CONCLUSION

The conclusion of our research will provide evidence to help physicians to decide between CTX and CNIs therapy regimens for IMN patients.

OPEN SCIENCE FRAMEWORK REGISTRATION NUMBER

10.17605/OSF.IO/G584K.

Effect of Nephritis Rehabilitation Tablets combined with tacrolimus in treatment of idiopathic membranous nephropathy

BACKGROUND

Idiopathic membranous nephropathy (IMN) has a high incidence in the middle-aged and elderly population, and poses a great threat to the physical and mental health and quality of life of patients. Nephritis Rehabilitation Tablets have many potential effects, such as clearing residual toxins, tumefying the kidney and spleen, replenishing qi, and nourishing yin, and have played an important role in the treatment of a variety of kidney diseases.

AIM

To investigate the efficacy and safety of Nephritis Rehabilitation Tablets combined with tacrolimus in the treatment of IMN.

METHODS

Eighty-four patients with IMN recruited from January 2017 to September 2020 were randomly divided into a study group (n = 42) and a control group (n = 42). On the basis of routine symptomatic treatment, both groups were treated with tacrolimus, and the study group was additionally treated with Nephritis Rehabilitation Tablets. Both groups were treated for 12 wk. The therapeutic effect, the levels of renal function indexes [serum creatinine (Scr), serum albumin, and 24-h urinary protein], urinary immunoglobulin (IgG4), membrane attack complex (C5b-9), and the incidence of adverse reactions were measured before and after 12 wk of treatment.

RESULTS

The total effective rate in the study group was significantly higher than that of the control group. Before treatment, there was no significant difference in Scr, serum albumin, or 24 h urinary protein between the two groups. After 12 wk of treatment, the levels of Scr and 24-h urinary protein in both groups were significantly lower and serum albumin was significantly higher than those before treatment (P < 0.05), and the levels of Scr and 24-h urinary protein were significantly lower (P = 0.003 and 0.000, respectively), and the level of serum albumin was significantly higher (P = 0.00) in the study group than in the control group. Before treatment, there was no significant difference in urinary IgG4 and C5b-9 levels between the study group and the control group (P = 0.336 and 0.438, respectively). After 12 wk of treatment, the levels of urinary IgG4 and C5b-9 in the two groups were lower than those before treatment, and the levels of urinary IgG4 and C5b-9 in the study group were significantly lower than those in the control group (P = 0.000). There was no significant difference in the incidence of adverse reactions between the two groups (P = 0.710).

CONCLUSION

Based on routine intervention, Nephritis Rehabilitation Tablets combined with tacrolimus in the treatment of IMN can effectively improve the renal function of patients and downregulate the expression of urinary IgG4 and C5b-9. In addition, they can improve the overall therapeutic effect while not increasing the risk of adverse reactions.

Electron-Dense Deposition Patterns and the Outcomes of Nephrotic Idiopathic Membranous Nephropathy Treated with Tacrolimus in Chinese Adults

Background

Tacrolimus may be effective in the short-term treatment of idiopathic membranous nephropathy (IMN). However, it is not clear whether an electron microscopic classification of the homogeneous and heterogeneous types of nephrotic IMN is related to the efficacy of tacrolimus in patients with IMN. This study aimed to explore this question and to provide evidence for individualized patient treatment.

Material/Methods

This 6-month retrospective study included 61 Chinese patients previously diagnosed with IMN. Patients received treatment was tacrolimus plus glucocorticoid. The patients were divided into a homogeneous group and a heterogeneous group based on the evaluation of electron-dense deposits. The initial clinicopathologic factors in the 2 groups were analyzed, and the difference in efficacy of tacrolimus in the 2 groups was assessed. The factors predicting remission were also studied.

Results

No significant alteration in the initial clinicopathologic status was found between the 2 groups, except for proteinuria, serum albumin levels, systolic blood pressure, and renal biopsy results (stages I/II/III/IV). After 3 months of treatment, the difference in remission was not significant between the 2 groups. However, after 6 months of treatment, a significant difference in remission rates was observed between the 2 groups. The binary logistic model showed that the homogeneous nephrotic IMN was independently associated with total remission (partial plus complete remission), and was also related to complete remission.

Conclusions

The results of our study revealed that the homogeneous type of nephrotic IMN had a higher short-term remission rate and a predictive value for partial or complete remission, and it might be a meaningful marker of the short-term response to tacrolimus.