A pilot study to determine the dose and effectiveness of adrenocorticotrophic hormone (H.P. Acthar® Gel) in nephrotic syndrome due to idiopathic membranous nephropathy.
BACKGROUND
H.P. Acthar(®) Gel is currently the only Food and Drug Administration therapy approved for the treatment of nephrotic syndrome. Active drug ingredients include structurally related melanocortin peptides that bind to cell surface G-protein-coupled receptors known as melanocortin receptors, which are expressed in glomerular podocytes. In animal models of membranous nephropathy, stimulation has been demonstrated to reduce podocyte injury and loss. We hypothesized that H.P. Acthar(®) Gel would improve symptoms of the nephrotic syndrome in patients with idiopathic membranous nephropathy.


METHODS
Twenty patients received a subcutaneous dose of 40 or 80 IU twice weekly. Changes in proteinuria, albumin, cholesterol profile, estimated glomerular filtration rate and serum anti-PLA2R antibodies were assessed at baseline and in response to treatment along with tolerance and safety.


RESULTS
Baseline characteristics included mean proteinuria (9.1 ± 3.4 g/day), albumin (2.7 ± 0.8 g/dL), estimated glomerular filtration rate (77 ± 30 mL/min) along with elevated total and low-density lipoprotein (LDL) cholesterol. By 12 months of follow-up, there was a significant improvement in proteinuria in the entire cohort, decreasing to 3.87 ± 4.24 g/day (P < 0.001) with significant improvements in serum albumin, total and LDL cholesterol. A >50% decrease in proteinuria was noted in 65% of the patients with a trend toward better outcomes among patients who received greater cumulative doses. No significant adverse effects were documented. Clearing of serum anti-PLA2R antibodies prior to or in parallel with proteinuria improvement was noted in some, but not all patients.


CONCLUSIONS
H.P. Acthar(®) Gel is a potential therapy for nephrotic syndrome secondary to idiopathic membranous nephropathy that deserves further study.
Division of Nephrology, University of Toronto for the Toronto Glomerulonephritis Registry, Toronto, ON, Canada.
Michelle A
MA
Hladunewich
Division of Nephrology, University of Toronto for the Toronto Glomerulonephritis Registry, Toronto, ON, Canada.
Daniel
D
Cattran
Division of Nephrology, Boston University School of Medicine, Boston, MA, USA.
Laurence H
LH
Beck
Division of Nephrology, University of Toronto for the Toronto Glomerulonephritis Registry, Toronto, ON, Canada.
Ayodele
A
Odutayo
Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
Sanjeev
S
Sethi
Division of Nephrology, Boston University School of Medicine, Boston, MA, USA.
Rivka
R
Ayalon
Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
Nelson
N
Leung
Division of Nephrology, University of Toronto for the Toronto Glomerulonephritis Registry, Toronto, ON, Canada.
Heather
H
Reich
Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
Fernando C
FC
Fervenza
D000324:Adrenocorticotropic Hormone / Q000008:administration & dosage*; D000328:Adult; D000368:Aged; D001706:Biopsy; D004305:Dose-Response Relationship, Drug; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate / Q000187:drug effects / Q000502:physiology*; D015433:Glomerulonephritis, Membranous / Q000150:complications* / Q000175:diagnosis; D006801:Humans; D007279:Injections, Subcutaneous; D007668:Kidney / Q000187:drug effects / Q000473:pathology / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D009404:Nephrotic Syndrome / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D010865:Pilot Projects; D016896:Treatment Outcome
D000324:Adrenocorticotropic Hormone
ACTH (H.P. Acthar® Gel); membranous nephropathy; nephrotic syndrome