[Application of guidelines in clinical practice: a multicenter analysis of the treatment of membranous glomerulonephritis in Piedmont, Italy].
The treatment of membranous glomerulonephritis (MGN) is controversial, especially in cases of no response to first-line treatment or multiple relapses. The Clinical Nephrology Group of Piedmont carried out a multicenter analysis of the treatment of patients affected by MGN in 15 nephrology units in Piedmont. The first treatment is usually started after a waiting period of 3-6 months in case of proteinuria in the nephrotic range but normal or slightly impaired renal function. A history of cancer, the presence of infectious disease, and secondary forms of MGN are criteria for exclusion from treatment. As first-line treatment, Piedmont nephrologists prescribe corticosteroids alternated with immunosuppressive drugs, generally preferring cyclophosphamide to chlorambucil. Only one nephrology unit uses cyclosporin A (CyA) as the first choice. In case of no response to treatment, a second therapeutic approach is undertaken after 2-12 months. Second-line treatment consists of CyA if immunosuppressive drugs were given before, and corticosteroids/ immunosuppressive drugs if CyA was the first treatment. A further choice may be ACTH or rituximab. In case of multiple relapses the treatment options are the same but previous immunosuppressive treatment, patient age, and the duration of kidney disease with a greater probability of renal failure and progression towards sclerosis require careful attention. Concern has been expressed regarding the potentially severe side effects of ACTH including myopathy, cataract and diabetes. In conclusion, the applied therapeutic approaches in Piedmont reflect the difficulty reported in the literature in identifying simple recommendations. ACTH and rituximab are increasingly preferred for the treatment of MGN and there is a need for prospective studies to determine the best protocol for rituximab and the safety profile of ACTH.
Nefrologia e Dialisi, Ospedale S.G. Bosco, Torino, Italy. cristina.rollino@libero.it
Cristiana
C
Rollino
Rosanna
R
Coppo
Franca
F
Giacchino
Silvana
S
Savoldi
Marco
M
Manganaro
Alessandro
A
Amore
Loredana
L
Colla
Michela
M
Ferro
Giovanni
G
Demicheli
Silvia
S
Berutti
Manuel
M
Burdese
Giuseppe
G
Paternoster
Raffaella
R
Cravero
Luisa
L
Benozzi
Giuseppe
G
Vagelli
Alessandra
A
Messuerotti
Carolina
C
Licata
Serena
S
Bainotti
Rosaria Rita
RR
Patti
Marco
M
Quaglia
Luigia
L
Costantini
Piero
P
Stratta
Giuseppe
G
Segoloni
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000324:Adrenocorticotropic Hormone / Q000627:therapeutic use; D058846:Antibodies, Monoclonal, Murine-Derived / Q000008:administration & dosage; D002699:Chlorambucil / Q000008:administration & dosage; D003520:Cyclophosphamide / Q000008:administration & dosage; D016572:Cyclosporine / Q000008:administration & dosage; D018450:Disease Progression; D004359:Drug Therapy, Combination; D015433:Glomerulonephritis, Membranous / Q000175:diagnosis / Q000188:drug therapy*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006728:Hormones / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007558:Italy; D017410:Practice Guidelines as Topic; D000069283:Rituximab; D016896:Treatment Outcome
D000305:Adrenal Cortex Hormones; D058846:Antibodies, Monoclonal, Murine-Derived; D006728:Hormones; D007166:Immunosuppressive Agents; D002699:Chlorambucil; D000069283:Rituximab; D016572:Cyclosporine; D003520:Cyclophosphamide; D000324:Adrenocorticotropic Hormone