title: Early initiation of immunosuppressive treatment in membranous nephropathy patients.
abstract: OBJECTIVE
  Suggestion for the management of idiopathic membranous nephropathy (IMN) includes 6 months of observation, followed with steroid plus alkylating agent. However, delayed immunosuppression exposes the kidneys to persistent damage. This study aimed to examine the benefit of early immunosuppression in IMN patients.
  
  
  METHODS
  A retrospective study was performed. From 1993 to 2013, 161 IMN patients were enrolled. Patients receiving immunosuppression within 6 months after diagnosis were classified as initial-treatment group, whereas other patients as initial-no-treatment group. The clinical outcomes and complication were examined.
  
  
  RESULTS
  Patients in the initial-treatment group had lower serum albumin concentration, less diabetes, and were younger. Steroid monotherapy is the main immunosuppression (64.5%) in this group. The initial-treatment group had a higher complete and partial remission rate than the initial-no-treatment group 6 months (52.9% vs. 35.0%, p=0.05) and 12 months (71.1% vs. 45.0%, p=0.003) after diagnosis. A similar result was seen between initial-steroid monotherapy and initial-no-treatment patients. Early immunosuppression is an independent predictor of remission within 1 year [hazard ratio (HR)=2.09; 95% confidence interval (CI)=1.25-3.49; p=0.005] and estimated glomerular filtration rate (eGFR) decline over 50% during the follow-up. (HR=0.33; 95% CI=0.13-0.86; p=0.02). The initial-treatment group also had a low frequency of eGFR decline over 50% (p=0.001) and low combined end-stage renal disease/mortality (p=0.001) compared with the initial-no-treatment group, but without more immunosuppression-related complication.
  
  
  CONCLUSIONS
  In contrast to Western countries, early immunosuppression (even steroid monotherapy) in our patients is associated with better remission in the 1styear and renal preserve. Further randomized controlled trials are needed to clarify the benefit of early immunosuppression in IMN patients, especially with oriental ethnic background.
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin Chu County, Taiwan.
authors.forename: Chieh Kai
authors.initials: CK
authors.lastname: Chan
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan.
authors.forename: Tai Shuan
authors.initials: TS
authors.lastname: Lai
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
authors.forename: Ping Min
authors.initials: PM
authors.lastname: Chen
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital, Jin-Shan Branch, New Taipei City, Taiwan.
authors.forename: Yu Hsiang
authors.initials: YH
authors.lastname: Chou
authors.affiliation: Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan.
authors.forename: Ching Fang
authors.initials: CF
authors.lastname: Wu
authors.affiliation: Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
authors.forename: Yen Ling
authors.initials: YL
authors.lastname: Chiu
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan. Electronic address: wcchiang@ntu.edu.tw.
authors.forename: Wen Chih
authors.initials: WC
authors.lastname: Chiang
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
authors.forename: Yung Ming
authors.initials: YM
authors.lastname: Chen
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
authors.forename: Tzong-Shinn
authors.initials: TS
authors.lastname: Chu
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
authors.forename: Kwan Dun
authors.initials: KD
authors.lastname: Wu
mesh_terms: D000328:Adult; D000368:Aged; D001379:Azathioprine / Q000627:therapeutic use; D003520:Cyclophosphamide / Q000627:therapeutic use; D016572:Cyclosporine / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D005260:Female; D005919:Glomerular Filtration Rate; D015433:Glomerulonephritis, Membranous / Q000150:complications* / Q000188:drug therapy* / Q000473:pathology; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D053208:Kaplan-Meier Estimate; D007668:Kidney / Q000473:pathology; D007676:Kidney Failure, Chronic / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011507:Proteinuria / Q000188:drug therapy* / Q000453:epidemiology; D012044:Regression Analysis; D012074:Remission Induction; D012189:Retrospective Studies; D013256:Steroids / Q000627:therapeutic use*; D013624:Taiwan
chemical_list: D007166:Immunosuppressive Agents; D013256:Steroids; D016572:Cyclosporine; D003520:Cyclophosphamide; D001379:Azathioprine
keywords: immunosuppression; membranous nephropathy; proteinuria; renal outcome; steroid