title: Restrictive use of immunosuppressive treatment in patients with idiopathic membranous nephropathy: high renal survival in a large patient cohort.
abstract: BACKGROUND
  Immunosuppressive treatment initiated at an early stage in patients with idiopathic membranous nephropathy (iMN) improves renal survival. Treatment should ideally be restricted to high-risk patients.
  
  
  OBJECTIVE
  To evaluate the efficacy of a restrictive immunosuppressive treatment strategy for patients with iMN.
  
  
  METHODS
  Prospective cohort study evaluating a predefined treatment protocol.
  
  
  METHODS
  From 1988, we adopted a restrictive treatment strategy: immunosuppressive treatment, mainly consisting of cyclophosphamide and steroids, was advised only in patients with renal insufficiency or severe intolerable nephrotic syndrome. We evaluated this strategy in a large patient cohort. To exclude any bias, we included all adult patients with iMN biopsied in the study period with a serum creatinine (Scr) < 135 micromol/l, a proteinuria > or = 3.0 g/day and/or a serum albumin (Salb) < or = 30 g/l at the time of biopsy. Analysis was according to the intention-to-treat principle.
  
  
  RESULTS
  We studied 69 patients. At the time of biopsy, mean age was 51 years, Scr 90 micromol/l, Salb 23 g/l and proteinuria 6.7 g/day. Average follow-up was 5.5 years. Thus far 33 (48%) patients have received immunosuppressive therapy, mainly because of renal insufficiency (n = 24). Status at the end of follow-up was: complete remission n = 22 (32%), partial remission n = 24 (35%), nephrotic syndrome n = 15 (22%), persistent proteinuria n = 1 (1.4%), ESRD n = 6 (8.7%), death n = 1 (1.4%; due to bladder carcinoma after cyclophosphamide therapy). Patient survival was 100% at 5 and 7 years. Renal survival was 94% at 5 years and 88% at 7 years.
  
  
  CONCLUSIONS
  In patients with iMN, a restrictive treatment policy assures a favourable prognosis, while preventing exposure to immunosuppressive therapy in >50% of the patients.
authors.affiliation: Department of Nephrology, University Medical Center St. Radboud, Nijmegen, The Netherlands. p.dubuf@nier.umcn.nl
authors.forename: P W G
authors.initials: PW
authors.lastname: du Buf-Vereijken
authors.forename: G W
authors.initials: GW
authors.lastname: Feith
authors.forename: D
authors.initials: D
authors.lastname: Hollander
authors.forename: P G G
authors.initials: PG
authors.lastname: Gerlag
authors.forename: J J J M
authors.initials: JJ
authors.lastname: Wirtz
authors.forename: T C
authors.initials: TC
authors.lastname: Noordzij
authors.forename: J F M
authors.initials: JF
authors.lastname: Wetzels
mesh_terms: D000328:Adult; D000368:Aged; D002699:Chlorambucil / Q000627:therapeutic use; D003520:Cyclophosphamide / Q000627:therapeutic use*; D005260:Female; D015433:Glomerulonephritis, Membranous / Q000188:drug therapy* / Q000473:pathology; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007668:Kidney / Q000473:pathology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012074:Remission Induction; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D007166:Immunosuppressive Agents; D002699:Chlorambucil; D003520:Cyclophosphamide