From the Guidelines
The current treatment options for membranous glomerulonephritis include both supportive care and immunosuppressive therapy, with a focus on minimizing harmful side effects and preventing disease progression, as recommended by the KDIGO 2021 guideline for the management of glomerular diseases 1.
Supportive Care
Supportive care focuses on blood pressure control using ACE inhibitors or ARBs (such as lisinopril 10-40 mg daily or losartan 25-100 mg daily), along with diuretics for edema management and statins for hyperlipidemia.
- Blood pressure control is crucial to slow disease progression.
- Diuretics and statins help manage edema and hyperlipidemia associated with nephrotic syndrome.
Immunosuppressive Therapy
For patients with nephrotic syndrome or declining kidney function, immunosuppressive therapy is recommended.
- First-line treatment typically involves rituximab (375 mg/m² weekly for 4 weeks or 1000 mg on days 1 and 15), which has shown excellent efficacy with fewer side effects than older regimens.
- Alternatively, a cyclical regimen of corticosteroids (methylprednisolone 1 g IV for 3 days, followed by oral prednisone 0.5 mg/kg/day) alternating with cyclophosphamide (2-3 mg/kg/day for 2-3 months) may be used.
- For patients with anti-PLA2R antibody-positive disease, monitoring antibody levels helps assess treatment response.
- Calcineurin inhibitors like cyclosporine (3-5 mg/kg/day in divided doses) or tacrolimus (0.05-0.1 mg/kg/day in divided doses) serve as alternative options, particularly in patients who cannot tolerate other immunosuppressants, as shown in a study by Cattran et al. 1.
Treatment Decisions
Treatment decisions should be individualized based on disease severity, risk of progression, and patient-specific factors, as membranous glomerulonephritis can spontaneously remit in about one-third of cases.
- The KDIGO 2021 guideline recommends choosing a treatment regimen that prevents disease progression and minimizes harmful side effects 1.
- A study by Alexopoulos et al. found that prolonged treatment with low-dose cyclosporin increases remission rates and is useful in maintaining remission 1.
- The KDOQI US commentary on the 2012 KDIGO clinical practice guideline for glomerulonephritis suggests that careful observation prior to initiating immunosuppressive treatment may be appropriate for some high-risk patients 1.
From the Research
Current Treatment Options for Membranous Glomerulonephritis
- Immunosuppressive therapy is a common treatment approach for membranous glomerulonephritis, with the goal of reducing proteinuria and slowing disease progression 2, 3, 4.
- The use of glucocorticoids, such as prednisone, in combination with alkylating agents, such as chlorambucil or cyclophosphamide, is a well-established treatment regimen for membranous glomerulonephritis 2, 4.
- Calcineurin inhibitors, such as cyclosporin or tacrolimus, may be used as an alternative or in combination with other immunosuppressive agents 3, 4, 5.
- Rituximab, a monoclonal antibody, has shown promise as a treatment option for patients with membranous glomerulonephritis who are dependent on calcineurin inhibitors or have failed other treatments 5, 6.
- Other immunosuppressive agents, such as mycophenolate mofetil, adrenocorticotropic hormone, and azathioprine, may be considered in certain cases, although the evidence for their use is limited 4, 6.
Treatment Considerations
- The decision to initiate immunosuppressive therapy should be based on the individual patient's risk of disease progression and the potential benefits and risks of treatment 2, 4, 6.
- Patients with membranous glomerulonephritis should be closely monitored for signs of treatment response and potential side effects, such as infection and malignancy 4.
- The use of supportive therapies, such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, may help to reduce proteinuria and slow disease progression 6.