Traditional treatment options for Membranous Nephropathy
Corticosteroids have been examined extensively in treatment of patients with Membranous Nephropathy with inconsistent outcomes.
In meta-analysis and a secondary pooled analysis, corticosteroid therapy alone was not associated with an increased rate of remission or preservation of kidney function.
Therefore corticosteroid therapy alone is not recommended for treatment of patients with MN.
Cytotoxic agents (cyclophosphamide, chlorambucil) in combination with corticosteroids have been studied in multiple trials and increase the rate of complete and partial remission and result in preservation of kidney function short term.
In the largest meta-analysis of 36 clinical trials, cytotoxic agents combined with corticosteroids were associated with a lower rate of mortality and ESRD and higher rate of complete and partial remissions but also led to a higher rate of adverse events.
Kidney Disease: Improving Global Outcomes currently recommends initial therapy to consist of a 6-month course of alternating monthly cycles of oral and intravenous corticosteroids and oral cyclophosphamide (grade 1B).
Calcineurin inhibitors (cyclosporin and tacrolimus) with or without corticosteroids have also been used in treatment of patients with primary MN and are associated with high rate of complete and partial remission; however, risk of relapse after discontinuation of the drug is similarly high.
If calcineurin inhibitors are used as first line therapy, we recommend treatment for at least 12 months, with a slow taper afterwards. However, lack of reduction in proteinuria >30% after 6 months of therapy with calcineurin inhibitor suggests resistance.
Several studies have evaluated the use of mycophenolate mofetil in patients with primary MN, but the outcomes have been disappointing and we do not recommend use of Mycophenolate Mofetil (MMF) monotherapy in this population.
