title: Have we changed the outcome in membranous nephropathy? A propensity study on the role of immunosuppressive therapy.
abstract: OBJECTIVE
  The long-term effect of immunosuppressive therapy (IS) on kidney survival in idiopathic membranous nephropathy (MGN) is debated. The introduction of renin angiotensin blockade, rigorous BP control, and the increasing age at presentation of patients with MGN adds further uncertainty. Given these important changes, we sought to determine whether implementation of IS has altered outcome.
  
  
  METHODS
  We prospectively evaluated 280 incident MGN patients from three distinct 10-year periods starting from 1975.
  
  
  RESULTS
  We found expected changes in treatment regimens but also variations in age, renal function, severity of proteinuria, and BP at presentation over this time. Outcomes did not differ over time if these significant variations in clinical characteristics were not accounted for across the eras. The effect of IS in the 57 patients treated with currently recommended regimens was assessed using propensity adjustment to address selection bias and the effect of newer, conservative therapies. A propensity score estimating the probability of receiving IS permitted the pairing of 39 treated patients with controls with similar high risk of progression of clinical features. Using this approach, IS was associated not only with remissions in proteinuria but also with substantially improved renal survival.
  
  
  CONCLUSIONS
  The study confirms that patient presenting characteristics and management regimens have changed significantly over time and the natural history of MGN has been altered. A study of propensity-matched patients confirms that current recommendations for IS have improved outcomes in MGN patients at high risk of progression.
authors.affiliation: Department of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. daniel.cattran@uhn.on.ca
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Cattran
authors.forename: Heather N
authors.initials: HN
authors.lastname: Reich
authors.forename: S Joseph
authors.initials: SJ
authors.lastname: Kim
authors.forename: Stéphan
authors.initials: S
authors.lastname: Troyanov
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000704:Analysis of Variance; D001794:Blood Pressure; D016009:Chi-Square Distribution; D018450:Disease Progression; D005260:Female; D015433:Glomerulonephritis, Membranous / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D053208:Kaplan-Meier Estimate; D007668:Kidney / Q000187:drug effects* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D009864:Ontario; D010818:Practice Patterns, Physicians' / Q000639:trends*; D057216:Propensity Score; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011507:Proteinuria / Q000188:drug therapy / Q000209:etiology; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D007166:Immunosuppressive Agents