From the Guidelines
The treatment for membranous nephropathy should prioritize rituximab as the first-line immunosuppressive regimen for high-risk patients, given its benefits in preventing progressive kidney failure and reducing complications, as recommended by the KDIGO 2021 clinical practice guideline 1. The approach to treating membranous nephropathy (MN) involves risk stratification, with conservative therapy for low-risk patients and immunosuppressive therapy for high-risk patients. Key aspects of conservative therapy include:
- Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) to reduce proteinuria
- Optimal blood pressure control (<130/80 mmHg)
- Dietary sodium restriction (<2g/day)
- Statins for hyperlipidemia
For high-risk patients with persistent nephrotic syndrome or declining kidney function, the preferred immunosuppressive regimen is rituximab, due to its favorable balance of benefits and harms compared to other options like cyclophosphamide, as noted in the KDIGO 2021 guideline 1. Alternative regimens may include calcineurin inhibitors (cyclosporine or tacrolimus) for 6-12 months. Supportive care measures are also crucial, including:
- Anticoagulation for patients with severe hypoalbuminemia and additional risk factors for thrombosis
- Management of edema with diuretics Treatment efficacy should be monitored through regular assessment of proteinuria, serum albumin, and kidney function, aiming for remission defined as proteinuria <3.5 g/day or <50% of baseline. This approach is supported by the most recent and highest quality evidence, prioritizing patient outcomes in terms of morbidity, mortality, and quality of life 1.
From the Research
Treatment Options for Membranous Nephropathy (MN)
The treatment options for MN include:
- Immunosuppressive therapies, such as corticosteroids alternating with alkylating agents, and calcineurin inhibitors 2
- Combination therapy with rituximab, low-dose cyclophosphamide, and prednisone, which has been shown to result in high rates of complete remission 3, 4
- Intravenous cyclophosphamide and oral prednisolone, which is a safe and effective treatment option for idiopathic membranous nephropathy 5
- Adrenocorticotropic hormone (ACTH) therapy, which may be considered for patients who do not respond to traditional therapies such as alkylating agents and calcineurin inhibitors 2
- Prednisolone and azathioprine, although treatment with this combination seems to be of no long-term benefit in ameliorating the clinical course of nephrotic patients with membranous nephropathy 6
Key Considerations
When considering treatment options for MN, it is essential to: