Membranous glomerulonephritis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Medical Therapy
First-line immunosuppressive therapy
- Cyclophosphamide plus glucocorticoids or a calcineurin inhibitor with low-dose or no glucocorticoids.
- Rituximab may be used with resistant patients.
- A random urine protein-to-creatinine ratio should not be used as initial and follow-up test to measure the progress of treatment.
- Patients with less than 4.0 g/day on a 24-hour urine collection should not be treated with immunosuppressive therapy. They should be monitored periodically for disease progression every three months for two years and twice yearly.
- Patients with protein excretion between 4.0 and 8.0 g/day on a 24-hour urine collection undergo spontaneous complete or partial remission over a period of three to six years.
- Glucocorticoids alone are not effective.
- Other drugs include mycophenolate mofetil, intravenous immune globulin, and synthetic adrenocorticotropic hormone.
- Cyclophosphamide and chlorambucil-based regimens are equally effective, as noted in a randomized head-to-head comparative trial that primarily enrolled moderate-risk patients (mean protein excretion 7 to 8 g/day and mean serum creatinine 1.05 mg/dL [93 micromol/L]) [28].
- Side effects
- The preferred regimen is oral prednisone (0.5 mg/kg per day) or methylprednisolone (0.4 mg/kg per day) given for months 1, 3, and 5 plus oral cyclophosphamide (2.0 to 2.5 mg/kg per day) given for months 2, 4, and 6.
- Cyclosporine plus low-dose prednisone (maximum of 10 mg/day)
- The cyclosporine-treated group had a significantly higher rate of complete (≤300 mg/day) or partial remission of proteinuria, which was defined as less than 3.5 g/day plus at least a 50 percent reduction from baseline (75 versus 22 percent with placebo). Renal function was the same in both groups. One year after the cessation of therapy, relapse of proteinuria was common, but 39 percent of treated patients were still in remission, compared to 13 percent with placebo. (See 'Relapsing disease' below.)
- The efficacy of tacrolimus (without glucocorticoids) was demonstrated in a randomized trial of 48 patients with MN who were treated with tacrolimus (0.05 mg/kg per day for 12 months with a six-month taper) or placebo [33]. The rate of complete or partial remission was significantly higher with tacrolimus at both 12 months (82 versus 24 percent) and 18 months (94 versus 35 percent).
- Rituximab may have benefit among patients with a moderate risk of progression who have not previously received immunosuppressive therapy.