title: Combination therapy with rituximab, low-dose cyclophosphamide, and prednisone for idiopathic membranous nephropathy: a case series.
abstract: BACKGROUND
  Membranous nephropathy is a common cause of the nephrotic syndrome. Treatment with standard regimens fails to induce complete remission in most patients. We evaluated the efficacy of combination therapy with rituximab, low-dose, oral cyclophosphamide, and an accelerated prednisone taper (RCP) for the treatment of idiopathic membranous nephropathy.
  
  
  METHODS
  We analyzed 15 consecutive patients with idiopathic membranous nephropathy treated with RCP at Massachusetts General Hospital. Seven patients (47%) received RCP as initial therapy, and the other eight patients (53%) received RCP for relapsing or refractory disease. All patients had at least 1 year of follow-up. The co-primary outcomes were attainment of partial and complete remission. Partial remission was defined as a urinary protein to creatinine ratio (UPCR) < 3 g/g and a 50% reduction from baseline. Complete remission was defined as a UPCR < 0.3 g/g. Secondary outcomes were serious adverse events and the change in proteinuria, serum creatinine, serum albumin, cholesterol, triglycerides, and immunoglobulin G levels after 1 year of treatment.
  
  
  RESULTS
  Over a median follow-up time of 37 (IQR, 34-44) months, 100% of patients achieved partial remission and 93% of patients achieved complete remission at a median time of 2 and 13 months, respectively. After 1 year of treatment, median (IQR) UPCR declined from 8.2 (6.6-11.1) to 0.3 (0.2-0.7) g/g (P < 0.001). Three serious adverse events occurred over 51 patient years. No patients died or progressed to ESKD.
  
  
  CONCLUSIONS
  Treatment of idiopathic membranous nephropathy with RCP resulted in high rates of complete remission. Larger studies evaluating this regimen are warranted.
authors.affiliation: Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, 101 Merrimac St, Boston, 02114, MA, USA. fcortazar@partners.org.
authors.forename: Frank B
authors.initials: FB
authors.lastname: Cortazar
authors.affiliation: Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: David E
authors.initials: DE
authors.lastname: Leaf
authors.affiliation: Division of Nephrology, Baylor University Medical Center at Dallas, Dallas, TX, USA.
authors.forename: Charles T
authors.initials: CT
authors.lastname: Owens
authors.affiliation: Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, 101 Merrimac St, Boston, 02114, MA, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Laliberte
authors.affiliation: Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, NC, USA.
authors.forename: William F
authors.initials: WF
authors.lastname: Pendergraft
authors.affiliation: Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, 101 Merrimac St, Boston, 02114, MA, USA.
authors.forename: John L
authors.initials: JL
authors.lastname: Niles
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage; D003520:Cyclophosphamide / Q000008:administration & dosage*; D004305:Dose-Response Relationship, Drug; D004338:Drug Combinations; D004359:Drug Therapy, Combination; D005260:Female; D015433:Glomerulonephritis, Membranous / Q000175:diagnosis* / Q000188:drug therapy*; D006801:Humans; D007155:Immunologic Factors / Q000008:administration & dosage; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011241:Prednisone / Q000008:administration & dosage*; D000069283:Rituximab / Q000008:administration & dosage*
chemical_list: D000893:Anti-Inflammatory Agents; D004338:Drug Combinations; D007155:Immunologic Factors; D007166:Immunosuppressive Agents; D000069283:Rituximab; D003520:Cyclophosphamide; D011241:Prednisone
keywords: Cyclophosphamide; Membranous nephropathy; Remission; Rituximab