Conservative versus immunosuppressive treatment of patients with idiopathic membranous nephropathy.
BACKGROUND
Treatment of idiopathic membranous glomerulonephritis (MGN) is a controversial issue. Whereas some authors recommend early immunosuppressive treatment of all patients with nephrotic syndrome, others do not support aggressive therapies, based on the spontaneous long-term favorable outcome of most patients. However, 20 to 50% of untreated patients develop progressive renal insufficiency.


METHODS
All of the patients with biopsy-proven MGN who developed renal insufficiency at our Hospital during the period of 1975 to 2000 were studied. Selected patients (N=39) were separated into two groups according to the two different therapeutic policies followed at our department: a conservative approach during the first period, 1975 to 1989 (group I, N=20), and a course of immunosuppressive therapy (oral prednisone for six months and concurrent oral chlorambucil, 0.15 mg/kg/day, during the first 14 weeks) during the second period, 1990 to 2000 (group II, N=19).


RESULTS
There were no significant differences between both groups at the time of renal biopsy, nor at the onset of renal function decline. All group I patients showed a progressive renal insufficiency; at the end of the follow-up 13 patients (65%) were on chronic dialysis, 2 (10%) showed advanced renal failure, and 5 (25%) had died. In contrast, most of group II patients showed an improvement or stabilization of serum creatinine (SCr; 2.3 +/- 0.9 mg/dL at onset of treatment, 2 +/- 1.5 mg/dL at the end of follow-up) together with decreased proteinuria (11.2 +/- 3.3 vs. 5.2 +/- 6.7 g/24 h). At the end of the follow-up 58% of group II patients had a SCr value < or =1.5 mg/dL and 36% showed a complete or partial remission, whereas no patient in group I showed remission. After four years of follow-up the probability of renal survival without dialysis was 55% in group I and 90% in group II (P < 0.001), and after seven years the renal survival was 20% and 90%, respectively (P < 0.001). Side effects of immunosuppressive treatment were uncommon but severe, as two patients suffered Pneumocystis carinii pneumonia.


CONCLUSIONS
A course of immunosuppressive treatment administered early at the onset of renal function decline induces a favorable effect in most of patients with MGN and deteriorating renal function. Untreated patients progressed without exception toward advanced renal failure.
Torres
Alvaro
A
Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.
Domínguez-Gil
Beatriz
B
Carreño
Agustín
A
Hernández
Eduardo
E
Morales
Enrique
E
Segura
Julian
J
González
Ester
E
Praga
Manuel
M
D000328:Adult; D000368:Aged; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage*; D018906:Antineoplastic Agents, Alkylating / Q000008:administration & dosage; D002699:Chlorambucil / Q000008:administration & dosage; D003404:Creatinine / Q000097:blood; D005260:Female; D005500:Follow-Up Studies; D015433:Glomerulonephritis, Membranous / Q000188:drug therapy* / Q000276:immunology*; D006801:Humans; D007165:Immunosuppression Therapy; D008297:Male; D008875:Middle Aged; D011241:Prednisone / Q000008:administration & dosage*; D011507:Proteinuria / Q000188:drug therapy / Q000276:immunology; D012189:Retrospective Studies; D016896:Treatment Outcome
D000893:Anti-Inflammatory Agents; D018906:Antineoplastic Agents, Alkylating; D002699:Chlorambucil; D003404:Creatinine; D011241:Prednisone