title: Relapse or worsening of nephrotic syndrome in idiopathic membranous nephropathy can occur even though the glomerular immune deposits have been eradicated.
abstract: BACKGROUND
  Relapse or worsening of nephrotic syndrome (NS) in idiopathic membranous nephropathy (IMN) is generally assumed to be due to recurrent disease. Here we document that often that may not be the case.
  
  
  METHODS
  This is a prospective study of 7 consecutive IMN patients whose renal status improved, then worsened after completing a course of immunosuppressive therapy. Each underwent detailed testing and repeat kidney biopsy.
  
  
  RESULTS
  In 4 patients (group A), the biopsy showed recurrent IMN (fresh subepithelial deposits). Immunosuppressive therapy was begun. In the other 3 patients (group B), the biopsy showed that the deposits had been eradicated. However, the glomerular basement membrane (GBM) was thickened and vacuolated. Immunosuppressive therapy was withheld. Groups A and B were comparable except that group B had very high intakes of salt and protein, based on 24-hour urine testing. Reducing their high salt intake sharply lowered proteinuria to the subnephrotic range and serum creatinine stabilized.
  
  
  CONCLUSIONS
  This work is the first to demonstrate that relapse/worsening of NS can occur in IMN even though the GBM deposits have been eradicated. High salt and protein intake in combination with thickened and vacuolated GBM appears to be the mechanism.
authors.affiliation: Departments of Internal Medicine and Pathology, The Ohio State University Medical Center, Columbus, Ohio 43210, USA.
authors.forename: Chadwick E
authors.initials: CE
authors.lastname: Barnes
authors.forename: William A
authors.initials: WA
authors.lastname: Wilmer
authors.forename: Raul A
authors.initials: RA
authors.lastname: Hernandez
authors.forename: Christopher
authors.initials: C
authors.lastname: Valentine
authors.forename: Leena S
authors.initials: LS
authors.lastname: Hiremath
authors.forename: Tibor
authors.initials: T
authors.lastname: Nadasdy
authors.forename: Anjali A
authors.initials: AA
authors.lastname: Satoskar
authors.forename: Rose L
authors.initials: RL
authors.lastname: Shim
authors.forename: Brad H
authors.initials: BH
authors.lastname: Rovin
authors.forename: Lee A
authors.initials: LA
authors.lastname: Hebert
mesh_terms: D000328:Adult; D000368:Aged; D003404:Creatinine / Q000097:blood; D004044:Dietary Proteins / Q000009:adverse effects; D018450:Disease Progression; D015433:Glomerulonephritis, Membranous / Q000150:complications / Q000188:drug therapy / Q000473:pathology*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007678:Kidney Glomerulus / Q000276:immunology / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009404:Nephrotic Syndrome / Q000178:diet therapy / Q000209:etiology*; D011446:Prospective Studies; D011507:Proteinuria / Q000209:etiology; D012008:Recurrence; D012964:Sodium / Q000652:urine; D017673:Sodium Chloride, Dietary / Q000009:adverse effects
chemical_list: D004044:Dietary Proteins; D007166:Immunosuppressive Agents; D017673:Sodium Chloride, Dietary; D012964:Sodium; D003404:Creatinine