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Zhang X, Dou J, Gao G, Sheng X, Shen Y, Feng Y, Wu X, Zhang Z, Cheng G. Comparison of tacrolimus with or without prednisone therapy in primary membranous nephropathy: a retrospective clinical study. Sci Rep 2024; 14:14214. [PMID: 38902302 PMCID: PMC11190188 DOI: 10.1038/s41598-024-64661-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/11/2024] [Indexed: 06/22/2024] Open
Abstract
Previous studies showed tacrolimus monotherapy and dual therapy with tacrolimus and prednisone as effective treatment modalities in managing membranous nephropathy. However, few studies have compared these therapeutic regimens. The patients were divided into two groups based on the treatment regimen: (1) tacrolimus and prednisone dual therapy (T + P group, n = 67) treatment group; and (2) tacrolimus monotherapy (T group, n = 65) or the control group. Propensity matching method and subgroup analysis to eliminate the bias in the relationship between the treatment regimen and the outcomes. The mean remission times were 20.33 ± 2.75 weeks at T group and 9.50 ± 1.81 weeks at T + P group. The T group had a remission rates of 73.33, 76.66 and 66.66% at 12weeks, 24weeks and 48weeks, while the T + P group had a remission rate of 81.66, 86.66, 91.66%; At the follow-up of 48 weeks, the relapse rate for the T group was 21.66%, and that for the T + P group was 5%. The anti-PLA2R ab is positive and therapy may be the independent risk factors for predicting remission. Tacrolimus and low-dose prednisone dual therapy is efficacious in managing MN and lowers the recurrence rate in clinical practice.
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Affiliation(s)
- Xinyue Zhang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingyu Dou
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ge Gao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoxiao Sheng
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ya Shen
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuhua Feng
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xueying Wu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen Zhang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Genyang Cheng
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Rui M, Jiang L, Pan JJ, Huang XT, Cui JF, Zhang SJ, He SM, Han HH, Chen X, Wang DD. Effects of tacrolimus on proteinuria in Chinese and Indian patients with idiopathic membranous nephropathy: the results of machine learning study. Int Urol Nephrol 2024:10.1007/s11255-024-04056-y. [PMID: 38642210 DOI: 10.1007/s11255-024-04056-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE The present study aims to explore the effects of tacrolimus on proteinuria in patients with idiopathic membranous nephropathy (IMN) and recommend an appropriate dosage schedule via machine learning method. METHODS The Emax model was constructed to analyze the effects of tacrolimus on proteinuria in patients with IMN. Data were mined from published literature and machine learning was built up with Emax model, among which the efficacy indicator was proteinuria change rates from baseline. 463 IMN patients were included for modeling, and tacrolimus therapeutic window concentrations were 4-10 ng/ml. RESULTS In machine learning model, the Emax from tacrolimus effecting proteinuria in IMN patients was -72.7%, the ET50 was 0.43 months, and the time to achieving 25% Emax, 50% Emax, 75% Emax, and 80% (plateau) Emax of tacrolimus on proteinuria in patients with IMN were 0.15, 0.43, 1.29, and 1.72 months, respectively. CONCLUSION For achieving better therapeutic effects from tacrolimus on proteinuria in patients with IMN, tacrolimus concentration range need to be maintained at 4-10 ng/ml for at least 1.72 months.
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Affiliation(s)
- Min Rui
- Department of Orthopaedics, The Affiliated Jiangyin Clinical College of Xuzhou Medical University, Jiangyin, 214400, Jiangsu, China
| | - Lei Jiang
- Department of Pharmacy, Taixing People's Hospital, Taixing, 225400, Jiangsu, China
| | - Jia-Jun Pan
- Department of Thoracic Cardiovascular Surgery, The Affiliated Xuzhou Municipal Hospital of Xuzhou Medical University, Xuzhou, 221100, Jiangsu, China
| | - Xue-Ting Huang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy and School of Pharmacy, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Jia-Fang Cui
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy and School of Pharmacy, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Shi-Jia Zhang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy and School of Pharmacy, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Su-Mei He
- Department of Pharmacy, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou, 215153, Jiangsu, China.
| | - Huan-Huan Han
- Department of Pharmacy, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, 222000, Jiangsu, China.
| | - Xiao Chen
- School of Nursing, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China.
| | - Dong-Dong Wang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy and School of Pharmacy, Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China.
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Zhang J, Fan Z, Wang P, Zhang AH. Phospholipase A2 Receptor Antibodies and Clinical Prognosis in Patients with Idiopathic Membranous Nephropathy: An Updated Systematic Review and Meta-Analysis. Kidney Blood Press Res 2023; 48:102-113. [PMID: 36720217 DOI: 10.1159/000529415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/23/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) is the most common form of primary nephrotic syndrome in adults. Antibodies against the M-type phospholipase A2 receptor (PLA2R-ab) are considered as diagnostic biomarkers of IMN. OBJECTIVE Here, we performed an updated meta-analysis to assess the diagnostic value of PLA2R-ab for clinical remission in IMN patients. METHOD PubMed, Embase, and Cochrane databases were searched for relevant studies published before September 2022. Odds ratios and corresponding 95% confidence intervals were determined using a fixed or random effects model. The heterogeneity among studies was explored by subgroup analysis. RESULTS Sixteen studies involving 1,761 IMN participants were included. There were significant differences between PLA2R-ab (+) and PLA2R-ab (-) patients in terms of complete remission (CR) and spontaneous remission. The rates of partial remission (PR) and relapse were similar between the two groups. Patients with PLA2R-ab (-) were at a higher CR rate when treated with a calcineurin inhibitor or a treatment course for 3 months and 6 months, while the spontaneous remission rate was higher in PLA2R-ab seronegative patients from Asia. However, the CR and spontaneous remission rate only significantly declined in IMN patients with the highest titer, but not a middle titer, when compared to those with the lowest titer. CONCLUSION In contrast with previous meta-analyses, our results verified that PLA2R-ab can likely predict CR and spontaneous remission in IMN patients, instead of PR and relapse. Race, immunosuppressive agents, and duration of treatment may affect the prognostic value of PLA2R-ab. Considering that the remission rate of IMN patients with a middle level of PLA2R-ab was not different from that of patients with the lowest level, a proper cut-off value of PLA2R-ab for prognosis should be clarified.
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Affiliation(s)
- Jialing Zhang
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China,
| | - Zhengjia Fan
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Peixin Wang
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ai-Hua Zhang
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
- The National Clinical Research Center for Geriatric Disease, Xuanwu Hospital, Capital Medical University, Beijing, China
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4
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Bose B, Chung EYM, Hong R, Strippoli GFM, Johnson DW, Yang WL, Badve SV, Palmer SC. Immunosuppression therapy for idiopathic membranous nephropathy: systematic review with network meta-analysis. J Nephrol 2022; 35:1159-1170. [PMID: 35199314 PMCID: PMC9107446 DOI: 10.1007/s40620-022-01268-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/01/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Idiopathic membranous nephropathy is a common cause of nephrotic syndrome in adults. The Kidney Disease Improving Global Outcomes guidelines recommend rituximab or cyclophosphamide and steroids, or calcineurin inhibitor-based therapy. However, there have been few or no head-to-head comparisons of the relative efficacy and safety of different immunosuppression regimens. We conducted a network meta-analysis to evaluate the comparative efficacy and safety of available immunosuppression strategies compared to cyclophosphamide in adults with idiopathic membranous nephropathy. METHODS We performed a systematic search of MEDLINE, Embase and CENTRAL for randomized controlled trials in the treatment of adults with idiopathic membranous nephropathy. The primary outcome was complete remission. Secondary outcomes were kidney failure, partial remission, estimated glomerular filtration rate, doubling of serum creatinine, proteinuria, serious adverse events, discontinuation of treatment, serious infection and bone marrow suppression. RESULTS Cyclophosphamide had uncertain effects on inducing complete remission when compared to rituximab (OR 0.35, CI 0.10-1.24, low certainty evidence), mycophenolate mofetil (OR 1.81, CI 0.69-4.71, low certainty), calcineurin inhibitor (OR 1.26, CI 0.61-2.63, low certainty) or steroid monotherapy (OR 2.31, CI 0.62-8.52, low certainty). Cyclophosphamide had a higher probability of inducing complete remission when compared to calcineurin inhibitor plus rituximab (OR 4.45, CI 1.04-19.10, low certainty). Compared to other immunosuppression strategies, there was limited evidence that cyclophosphamide had different effects on other pre-specified outcomes. CONCLUSIONS The comparative effectiveness and safety of immunosuppression strategies compared to cyclophosphamide is uncertain in adults with idiopathic membranous nephropathy.
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Affiliation(s)
- Bhadran Bose
- Australasian Kidney Trials Network, The University of Queensland, Queensland, Australia.
- Department of Nephrology, Nepean Hospital, Kingswood, NSW, 2747, Australia.
| | - Edmund Y M Chung
- Centre for Kidney Research, Cochrane Kidney and Transplant, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Regina Hong
- Department of Nephrology, St George Hospital, Sydney, Australia
| | - Giovanni F M Strippoli
- Centre for Kidney Research, Cochrane Kidney and Transplant, The Children's Hospital at Westmead, Westmead, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, The University of Queensland, Queensland, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Wen-Ling Yang
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Sunil V Badve
- Australasian Kidney Trials Network, The University of Queensland, Queensland, Australia
- Department of Nephrology, St George Hospital, Sydney, Australia
- UNSW Medicine, The George Institute for Global Health, Sydney, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
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5
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von Groote TC, Williams G, Au EH, Chen Y, Mathew AT, Hodson EM, Tunnicliffe DJ. Immunosuppressive treatment for primary membranous nephropathy in adults with nephrotic syndrome. Cochrane Database Syst Rev 2021; 11:CD004293. [PMID: 34778952 PMCID: PMC8591447 DOI: 10.1002/14651858.cd004293.pub4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Primary membranous nephropathy (PMN) is a common cause of nephrotic syndrome in adults. Without treatment, approximately 30% of patients will experience spontaneous remission and one third will have persistent proteinuria. Approximately one-third of patients progress toward end-stage kidney disease (ESKD) within 10 years. Immunosuppressive treatment aims to protect kidney function and is recommended for patients who do not show improvement of proteinuria by supportive therapy, and for patients with severe nephrotic syndrome at presentation due to the high risk of developing ESKD. The efficacy and safety of different immunosuppressive regimens are unclear. This is an update of a Cochrane review, first published in 2004 and updated in 2013. OBJECTIVES The aim was to evaluate the safety and efficacy of different immunosuppressive treatments for adult patients with PMN and nephrotic syndrome. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 1 April 2021 with support from the Cochrane Kidney and Transplant Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) investigating effects of immunosuppression in adults with PMN and nephrotic syndrome were included. DATA COLLECTION AND ANALYSIS Study selection, data extraction, quality assessment, and data synthesis were performed using Cochrane-recommended methods. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Sixty-five studies (3807 patients) were included. Most studies exhibited a high risk of bias for the domains, blinding of study personnel, participants and outcome assessors, and most studies were judged unclear for randomisation sequence generation and allocation concealment. Immunosuppressive treatment versus placebo/no treatment/non-immunosuppressive treatment In moderate certainty evidence, immunosuppressive treatment probably makes little or no difference to death, probably reduces the overall risk of ESKD (16 studies, 944 participants: RR 0.59, 95% CI 0.35 to 0.99; I² = 22%), probably increases total remission (complete and partial) (6 studies, 879 participants: RR 1.44, 95% CI 1.05 to 1.97; I² = 73%) and complete remission (16 studies, 879 participants: RR 1.70, 95% CI 1.05 to 2.75; I² = 43%), and probably decreases the number with doubling of serum creatinine (SCr) (9 studies, 447 participants: RR 0.46, 95% CI 0.26 to 0.80; I² = 21%). However, immunosuppressive treatment may increase the number of patients relapsing after complete or partial remission (3 studies, 148 participants): RR 1.73, 95% CI 1.05 to 2.86; I² = 0%) and may lead to a greater number experiencing temporary or permanent discontinuation/hospitalisation due to adverse events (18 studies, 927 participants: RR 5.33, 95% CI 2.19 to 12.98; I² = 0%). Immunosuppressive treatment has uncertain effects on infection and malignancy. Oral alkylating agents with or without steroids versus placebo/no treatment/steroids Oral alkylating agents with or without steroids had uncertain effects on death but may reduce the overall risk of ESKD (9 studies, 537 participants: RR 0.42, 95% CI 0.24 to 0.74; I² = 0%; low certainty evidence). Total (9 studies, 468 participants: RR 1.37, 95% CI 1.04 to 1.82; I² = 70%) and complete remission (8 studies, 432 participants: RR 2.12, 95% CI 1.33 to 3.38; I² = 37%) may increase, but had uncertain effects on the number of patients relapsing, and decreasing the number with doubling of SCr. Alkylating agents may be associated with a higher rate of adverse events leading to discontinuation or hospitalisation (8 studies 439 participants: RR 6.82, 95% CI 2.24 to 20.71; I² = 0%). Oral alkylating agents with or without steroids had uncertain effects on infection and malignancy. Calcineurin inhibitors (CNI) with or without steroids versus placebo/no treatment/supportive therapy/steroids We are uncertain whether CNI with or without steroids increased or decreased the risk of death or ESKD, increased or decreased total or complete remission, or reduced relapse after complete or partial remission (low to very low certainty evidence). CNI also had uncertain effects on decreasing the number with a doubling of SCr, temporary or permanent discontinuation or hospitalisation due to adverse events, infection, or malignancy. Calcineurin inhibitors (CNI) with or without steroids versus alkylating agents with or without steroids We are uncertain whether CNI with or without steroids increases or decreases the risk of death or ESKD. CNI with or without steroids may make little or no difference to total remission (10 studies, 538 participants: RR 1.01, 95% CI 0.89 to 1.15; I² = 53%; moderate certainty evidence) or complete remission (10 studies, 538 participants: RR 1.15, 95% CI 0.84 to 1.56; I² = 56%; low certainty evidence). CNI with or without steroids may increase relapse after complete or partial remission. CNI with or without steroids had uncertain effects on SCr increase, adverse events, infection, and malignancy. Other immunosuppressive treatments Other interventions included azathioprine, mizoribine, adrenocorticotropic hormone, traditional Chinese medicines, and monoclonal antibodies such as rituximab. There were insufficient data to draw conclusions on these treatments. AUTHORS' CONCLUSIONS This updated review strengthened the evidence that immunosuppressive therapy is probably superior to non-immunosuppressive therapy in inducing remission and reducing the number of patients that progress to ESKD. However, these benefits need to be balanced against the side effects of immunosuppressive drugs. The number of included studies with high-quality design was relatively small and most studies did not have adequate follow-up. Clinicians should inform their patients of the lack of high-quality evidence. An alkylating agent (cyclophosphamide or chlorambucil) combined with a corticosteroid regimen had short- and long-term benefits, but this was associated with a higher rate of adverse events. CNI (tacrolimus and cyclosporin) showed equivalency with alkylating agents however, the certainty of this evidence remains low. Novel immunosuppressive treatments with the biologic rituximab or use of adrenocorticotropic hormone require further investigation and validation in large and high-quality RCTs.
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Affiliation(s)
- Thilo C von Groote
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hosptial Münster, Münster, Germany
| | | | - Eric H Au
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - Yizhi Chen
- Department of Nephrology, Hainan Hospital of Chinese PLA General Hospital, Hainan Provincial Academician Team Innovation Center, Sanya, China
- Senior Department of Nephrology, the First Medical Center of Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Anna T Mathew
- Department of Nephrology, McMaster University, Hamilton, Canada
| | - Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 797] [Impact Index Per Article: 265.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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7
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Floege J, Rovin BH. The STARMEN trial: rethinking calcineurin inhibitor therapy in membranous nephropathy. Kidney Int 2021; 99:811-813. [PMID: 33745547 DOI: 10.1016/j.kint.2020.11.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/17/2020] [Indexed: 10/21/2022]
Abstract
The STARMEN trial postulated that in primary membranous nephropathy (pMN) treatment with tacrolimus plus rituximab would be superior to a traditional Ponticelli regimen of alternating cyclophosphamide and glucocorticoids. This was not the case. Significantly more remissions were achieved in cyclophosphamide-treated patients, and more of these were complete remissions. Considering these results with those of the Mentor trial, which compared rituximab with cyclosporine in pMN, we offer an evidence-based perspective on the role of calcineurin inhibition for pMN treatment.
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Affiliation(s)
- Jürgen Floege
- Division of Nephrology, RWTH Aachen University Hospital, Aachen, Germany
| | - Brad H Rovin
- Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
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8
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Wu L, Lai J, Ling Y, Weng Y, Zhou S, Wu S, Jiang S, Ding X, Jin X, Yu K, Chen Y. A Review of the Current Practice of Diagnosis and Treatment of Idiopathic Membranous Nephropathy in China. Med Sci Monit 2021; 27:e930097. [PMID: 33550324 PMCID: PMC7876949 DOI: 10.12659/msm.930097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Idiopathic membranous nephropathy (IMN), a common pathological type of nephrotic syndrome, is one of the main causes of kidney failure. With an increasing prevalence, IMN has received considerable attention in China. Based on recent studies, we discuss advances in the diagnosis of IMN and the understanding of its genetic background. Although the pathogenesis of IMN remains unclear, our understanding has been substantially enhanced by the discovery of new antigens such as phospholipase A2 receptor, thrombospondin type-1 domain-containing 7A, exostosin1/exostosin2, neural epidermal growth factor-like 1 protein, neural cell adhesion molecule 1, semaphorin 3B, and factor H autoantibody. However, due to ethnic, environmental, economic, and lifestyle differences and other factors, a consensus has not yet been reached regarding IMN treatment. In view of the differences between Eastern and Western populations, in-depth clinical evaluations of biomarkers for IMN diagnosis are necessary. This review details the current treatment strategies for IMN in China, including renin-angiotensin system inhibitors, corticosteroid monotherapy, cyclophosphamide, calcineurin inhibitors, mycophenolate mofetil, adrenocorticotropic hormone, and traditional Chinese medicine, as well as biological preparations such as rituximab. In terms of management, the 2012 Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines do not fully consider the characteristics of the Chinese population. Therefore, this review aims to present the current status of IMN diagnosis and treatment in Chinese patients, and includes a discussion of new approaches and remaining clinical challenges.
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Affiliation(s)
- Lianzhong Wu
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland).,Department of Hematology, Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Jin Lai
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland).,Department of Hematology, Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Yixin Ling
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland).,Department of Hematology, Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Yiqin Weng
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland).,Department of Hematology, Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Shujuan Zhou
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Siqi Wu
- Department of Hematology, Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Songfu Jiang
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Xiaokai Ding
- Department of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Xin Jin
- Department of Clinical Laboratory, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China (mainland)
| | - Kang Yu
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Yi Chen
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
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9
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Di J, Qian Q, Yang M, Jiang Y, Zhou H, Li M, Zou Y. Efficacy and safety of long-course tacrolimus treatment for idiopathic membranous nephropathy. Exp Ther Med 2018; 16:979-984. [PMID: 30116348 DOI: 10.3892/etm.2018.6211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 03/09/2018] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to observe the efficacy and safety of long-course treatment with tacrolimus combined with low-dose corticosteroids for idiopathic membranous nephropathy (IMN). A total of 76 patients with IMN diagnosed by renal biopsy between March 2012 and January 2016 form The First People's Hospital of Changzhou (Changzhou, China) were selected and randomly divided into a short-course group and a long-course group (each, n=38). Patients in the short-course group were treated with hormone combined with tacrolimus for 12 months, whereas those in the long-course group received the same treatment for 24 months. The efficacy, safety and recurrence of the two groups of patients were observed, and serum ALB, urine protein, Scr and blood glucose were assessed once a month for 24 months by measuring blood biochemistry. A total of 11 patients exhibited adverse effects, 6 of whom were serious and as such were excluded from the study. In the short-course group, 8 of 35 patients demonstrated complete remission (CR), 17 patients exhibited partial remission (PR) and the remaining 10 patients had no remission (NR); however the disease recurred in 8 patients following treatment. In the long-course group, 16 of 35 patients exhibited CR, 14 patients demonstrated PR and the remaining 5 patients had NR. Furthermore, the disease recurred in 4 patients following treatment. Significant differences were observed in urine protein and serum ALB at 18 and 24 months following treatment between the two groups while Scr and blood glucose had no significant differences at any time point. It was concluded that long-course tacrolimus combined with low-dose hormone effectively treats idiopathic membranous nephropathy and that therapy demonstrated a relatively high remission rate, and the recurrence rate of the disease is low.
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Affiliation(s)
- Jia Di
- Department of Nephrology, The First People's Hospital of Changzhou, Changzhou, Jiangsu 213003, P.R. China
| | - Qing Qian
- Department of Pharmacy, The First People's Hospital of Changzhou, Changzhou, Jiangsu 213003, P.R. China
| | - Min Yang
- Department of Nephrology, The First People's Hospital of Changzhou, Changzhou, Jiangsu 213003, P.R. China
| | - Yaping Jiang
- Department of Nephrology, The First People's Hospital of Changzhou, Changzhou, Jiangsu 213003, P.R. China
| | - Hua Zhou
- Department of Nephrology, The First People's Hospital of Changzhou, Changzhou, Jiangsu 213003, P.R. China
| | - Min Li
- Department of Nephrology, The First People's Hospital of Changzhou, Changzhou, Jiangsu 213003, P.R. China
| | - Yun Zou
- Department of Nephrology, The First People's Hospital of Changzhou, Changzhou, Jiangsu 213003, P.R. China
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Liang Q, Li H, Xie X, Qu F, Li X, Chen J. The efficacy and safety of tacrolimus monotherapy in adult-onset nephrotic syndrome caused by idiopathic membranous nephropathy. Ren Fail 2018; 39:512-518. [PMID: 28562168 PMCID: PMC6014322 DOI: 10.1080/0886022x.2017.1325371] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction: The purpose of the study is to evaluate the efficiency and safety of tacrolimus (TAC) monotherapy in the treatment of nephrotic idiopathic membranous nephropathy (IMN) compared with the protocol of cyclophosphamide (CTX) combined with corticosteroids. Methods: In total, 58 patients with nephrotic syndrome and biopsy-proven IMN were included in this study. 30 patients received TAC monotherapy with an initial dose of 0.05–0.1 mg/kg/day. 28 patients received transvenous CTX at a dose of 0.5–0.75 g/m2 once in every month initially for 6 months and once in every 2 or 3 months for the later period, and the regimen was combined with corticosteroids (prednisone 1 mg/kg/d). All patients were observed for the treatment effects, recurrence and side effects. Results: Twelve months after the initial treatment, a total of 24 (80%) patients in the TAC group and 23 (82.1%) patients in the CTX group achieved remission (either partial or complete remission). The survival curve of the probability of remission and complete remission were similar between the two groups (p > .05). Proteinuria (based on 24 h urinary protein excretion) was significantly decreased, and serum albumin was significantly increased after immunosuppressive treatment in both the groups. Estimated glomerular filtration rate (eGFR) was comparable between before and after treatment. The main adverse effects in TAC treatment were glucose intolerance, diabetes and abnormal aminotransferase. Conclusions: TAC monotherapy is an alternative therapeutic regimen for patients with nephrotic IMN. Its short-term efficiency and patient tolerance are both acceptable.
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Affiliation(s)
- Qian Liang
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Heng Li
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Xishao Xie
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Fangzhi Qu
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Xiayu Li
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Jianghua Chen
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
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11
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Hamilton P, Kanigicherla D, Venning M, Brenchley P, Meads D. Rituximab versus the modified Ponticelli regimen in the treatment of primary membranous nephropathy: a Health Economic Model. Nephrol Dial Transplant 2018; 33:2145-2155. [DOI: 10.1093/ndt/gfy049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 01/28/2018] [Indexed: 01/15/2023] Open
Affiliation(s)
- Patrick Hamilton
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Durga Kanigicherla
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Michael Venning
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Paul Brenchley
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, Leeds, UK
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12
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Zhang H, Liu Z, Zhou M, Liu Z, Chen J, Xing C, Lin H, Ni Z, Fu P, Liu F, Chen N, He Y, Liu J, Zeng C, Liu Z. Multitarget Therapy for Maintenance Treatment of Lupus Nephritis. J Am Soc Nephrol 2017; 28:3671-3678. [PMID: 28760751 DOI: 10.1681/asn.2017030263] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 06/08/2017] [Indexed: 02/05/2023] Open
Abstract
Our previous studies showed that multitarget therapy is superior in efficacy to intravenous cyclophosphamide as an induction treatment for lupus nephritis in Asian populations. We conducted an open label, multicenter study for 18 months as an extension of the prior induction therapy trial in 19 renal centers in China to assess the efficacy and safety of multitarget maintenance therapy in patients who had responded at 24 weeks during the induction phase. Patients who had undergone multitarget induction therapy continued to receive multitarget therapy (tacrolimus, 2-3 mg/d; mycophenolate mofetil, 0.50-0.75 g/d; prednisone, 10 mg/d), and patients who had received intravenous cyclophosphamide induction treatment received azathioprine (2 mg/kg per day) plus prednisone (10 mg/d). We assessed the renal relapse rate during maintenance therapy as the primary outcome. We recruited 116 patients in the multitarget group and 90 patients in the azathioprine group. The multitarget and azathioprine groups had similar cumulative renal relapse rates (5.47% versus 7.62%, respectively; adjusted hazard ratio, 0.82; 95% confidence interval, 0.25 to 2.67; P=0.74), and serum creatinine levels and eGFR remained stable in both groups. The azathioprine group had more adverse events (44.4% versus 16.4% for multitarget therapy; P<0.01), and the multitarget group had a lower withdrawal rate due to adverse events (1.7% versus 8.9% for azathioprine; P=0.02). In conclusion, multitarget therapy as a maintenance treatment for lupus nephritis resulted in a low renal relapse rate and fewer adverse events, suggesting that multitarget therapy is an effective and safe maintenance treatment for patients with lupus nephritis.
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Affiliation(s)
- Haitao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhengzhao Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Minlin Zhou
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhangsuo Liu
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Jianghua Chen
- Department of Nephrology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongli Lin
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | | | - Ping Fu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Fuyou Liu
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Nan Chen
- Ruijin Hospitals, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yongcheng He
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China; and
| | - Jianshe Liu
- Department of Nephrology, Wuhan Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China;
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13
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Cui W, Lu X, Min X, Liu M, Guan S, Wang Y, Luo M, Li W, Li Q, Dong W, Miao L, Luo P. Therapy of tacrolimus combined with corticosteroids in idiopathic membranous nephropathy. ACTA ACUST UNITED AC 2017; 50:e5976. [PMID: 28355356 PMCID: PMC5423753 DOI: 10.1590/1414-431x20175976] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/24/2017] [Indexed: 12/13/2022]
Abstract
We evaluated the efficacy and safety of tacrolimus (TAC) combined with corticosteroids in treating patients with idiopathic membranous nephropathy (IMN). One hundred seventy-seven biopsy-proven IMN patients were recruited in this retrospective clinical study. Sixty patients received TAC (target blood concentration of 4–8 ng/mL) and 117 patients received daily cyclophosphamide (CYC, 100 mg) combined with prednisone. Remission rates at the end of the first, second and third month in the TAC group were significantly higher than that in the CYC group (1st: 35.0 vs 19.7%, P<0.05; 2nd: 56.7 vs 38.5%, P<0.05; 3rd: 76.7 vs 59.0%, P<0.05). In the first 3 months, daily urinary protein and serum albumin in the TAC group obtained a better improvement than that in the CYC group (P<0.05). At the end of the sixth and the twelfth month, the remission rates, daily urinary protein and serum albumin were all comparable between the two groups (P>0.05). No significant difference of relapse rate between the groups was found (16.3 vs 12.0%, P>0.05). Patients were more likely to develop glucose intolerance in the TAC group. The TAC regimen obtained more benefits in treating IMN patients, especially in the first 3 months, than the CYC regimen.
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Affiliation(s)
- W Cui
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China
| | - X Lu
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China
| | - X Min
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China
| | - M Liu
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China
| | - S Guan
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China
| | - Y Wang
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China
| | - M Luo
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China
| | - W Li
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China
| | - Q Li
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China.,Department of Nephrology, Central Hospital of Jilin City, Jilin, China
| | - W Dong
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China.,Department of Nephrology, General Hospital of Daqing Oil Field, Daqing, China
| | - L Miao
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China
| | - P Luo
- Department of Nephrology, the Second Hospital of Jilin University, Jilin, China
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Efficacy and Safety of Tacrolimus Versus Cyclophosphamide for Primary Membranous Nephropathy: A Meta-Analysis. Drugs 2017; 77:187-199. [DOI: 10.1007/s40265-016-0683-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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15
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Comparison of the Efficacy of Tacrolimus Versus Cyclosporine in the Treatment of Idiopathic Membranous Nephropathy. Nephrourol Mon 2016. [DOI: 10.5812/numonthly.42473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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van de Logt AE, Hofstra JM, Wetzels JF. Pharmacological treatment of primary membranous nephropathy in 2016. Expert Rev Clin Pharmacol 2016; 9:1463-1478. [DOI: 10.1080/17512433.2016.1225497] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Anne-Els van de Logt
- Radboud Institute for Health Sciences, Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Julia M. Hofstra
- Radboud Institute for Health Sciences, Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack F. Wetzels
- Radboud Institute for Health Sciences, Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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Peng L, Wei SY, Li LT, He YX, Li B. Comparison of different therapies in high-risk patients with idiopathic membranous nephropathy. J Formos Med Assoc 2016; 115:11-8. [DOI: 10.1016/j.jfma.2015.07.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 07/19/2015] [Accepted: 07/27/2015] [Indexed: 10/23/2022] Open
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18
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Efficacy and safety of tacrolimus vs. cyclophosphamide for idiopathic membranous nephropathy: A meta-analysis of Chinese adults. ACTA ACUST UNITED AC 2015; 35:623-628. [DOI: 10.1007/s11596-015-1480-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 06/17/2015] [Indexed: 10/22/2022]
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