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Controversies in the treatment of idiopathic membranous nephropathy

Nature Reviews Nephrology volume 5, pages 469–479 (2009)Cite this article

Abstract

Optimum treatment of idiopathic membranous nephropathy is both controversial and challenging. The most extensively studied and frequently used immunosuppressive regimens for this disease comprise alkylating agents plus corticosteroids or ciclosporin. All of these treatment options have inherent problems: they are not effective in all patients, partial—rather than complete—remissions are common, adverse effects are worrisome, and relapses after treatment cessation remain problematic. Alternative immunosuppressive agents have been tested in an effort to overcome these unresolved issues. This paper reviews the available evidence regarding both established and new agents for the treatment of patients with idiopathic membranous nephropathy, with an emphasis on the results of the most recent clinical trials.

Key Points

  • Patients with idiopathic membranous nephropathy (IMN) who have a low risk of progression to end-stage renal disease are not usually treated with immunosuppressants

  • The criteria for immunosuppressive treatment in patients with the nephrotic syndrome who have stable, preserved renal function are debated

  • For patients with IMN who are at medium or high risk of disease progression, the most extensively studied immunosuppressive regimens comprise ciclosporin or cytotoxic agents, in combination with steroids

  • Relapses of the nephrotic syndrome after cessation of treatment are a common problem in IMN

  • Favorable experience of the use of rituximab in IMN is growing, but this agent is still considered an experimental therapy at present

  • Adrenocorticotropic hormone and mycophenolate mofetil might have a role in IMN, but evidence is still too limited to make formal recommendations regarding the routine use of these treatments

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Acknowledgements

The authors are grateful to Drs James Balow and Monique Cho for their critical reading of this manuscript. This work was supported by the Intramural Research Program of the National Institute of Diabetes and Digestive and Kidney Diseases, NIH.

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  1. Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA

    Meryl Waldman & Howard A. Austin III

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Waldman, M., Austin III, H. Controversies in the treatment of idiopathic membranous nephropathy. Nat Rev Nephrol 5, 469–479 (2009). https://doi.org/10.1038/nrneph.2009.101

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