title: A new rescue regimen with plasma exchange and rituximab in high-risk membranous glomerulonephritis.
abstract: BACKGROUND
  Even though current treatment guidelines for idiopathic membranous glomerulonephritis (iMGN) exist, many questions regarding an optimal therapy remain unanswered. Complete remission cannot be achieved in all patients; relapses occur, in some cases frequently, and side effects from the immunosuppressive therapy are common. Therapeutic options in high-risk patients not responding to standard immunosuppressive therapies are limited. Recent research reveals that the human M-type phospholipase A2 receptor (PLA2 R) is a causative factor in iMGN that parallels clinical disease activity. However, in some patients, this correlation is not evident and additional undetermined factors seem to play a role.
  
  
  METHODS
  We evaluated a new rescue protocol including plasma exchanges (PE) against albumin, intravenous immunoglobulins (IVIGs) and rituximab for 10 patients with a biopsy-proven diagnosis of iMGN who were therapy-resistant to all conventional regimens and had a urinary protein to creatinine ratio of more than 10 000 mg/g Crea. We compared this protocol with standard immunosuppressive protocols including monthly alternating prednisolone plus cyclophosphamide (18 patients), cyclosporine plus prednisolone (23 patients) and rituximab alone (eight patients) in a retrospective design.
  
  
  RESULTS
  Our rescue regimen with PE, IVIGs and rituximab achieved partial remission in 90% of patients who had been otherwise refractory to therapy. The mean time to partial remission was 2·1 months. Furthermore, two anti-PLA2 R-antibody negative patients were also treated with this rescue regimen, achieving partial remission after 1 and 4 months.
  
  
  CONCLUSIONS
  A combination of PE, IVIGs and rituximab is a treatment option to consider for high-risk patients with iMGN who are refractory to conventional therapy.
authors.affiliation: Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany.
authors.forename: Janina
authors.initials: J
authors.lastname: Müller-Deile
authors.affiliation: Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany.
authors.forename: Lena
authors.initials: L
authors.lastname: Schiffer
authors.affiliation: Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany.
authors.forename: Marcus
authors.initials: M
authors.lastname: Hiss
authors.affiliation: Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany.
authors.forename: Hermann
authors.initials: H
authors.lastname: Haller
authors.affiliation: Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany.
authors.forename: Mario
authors.initials: M
authors.lastname: Schiffer
mesh_terms: D000284:Administration, Oral; D003520:Cyclophosphamide / Q000008:administration & dosage; D016572:Cyclosporine / Q000008:administration & dosage; D004359:Drug Therapy, Combination; D005260:Female; D015433:Glomerulonephritis, Membranous / Q000628:therapy*; D005938:Glucocorticoids / Q000008:administration & dosage; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000008:administration & dosage; D007155:Immunologic Factors / Q000008:administration & dosage*; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage; D008875:Middle Aged; D010951:Plasma Exchange / Q000379:methods*; D011239:Prednisolone / Q000008:administration & dosage; D012008:Recurrence; D012074:Remission Induction / Q000379:methods; D012189:Retrospective Studies; D000069283:Rituximab / Q000008:administration & dosage*
chemical_list: D005938:Glucocorticoids; D016756:Immunoglobulins, Intravenous; D007155:Immunologic Factors; D007166:Immunosuppressive Agents; D000069283:Rituximab; D016572:Cyclosporine; D003520:Cyclophosphamide; D011239:Prednisolone; D008775:Methylprednisolone
keywords: idiopathic membranous glomerulonephritis; maintenance therapy; partial remission; plasma exchange; rescue therapy; rituximab