Immune suppressive treatment of membranous glomerulonephritis

We studied the effectiveness of a new, improved form of immune suppressive (IS) treatment in membranous glomerulonephritis (MGN). The treatment consisted of four phases: 1) Induction with i.v. boluses of methylprednisolone plus oral cyclophosphamide (CPM); 2) Maintenance with oral prednisone (PDN) in an alternate day regimen and daily oral doses of CPM; 3) Tapering, during which PDN alone was slowly decreased; 4) Discontinuation when CPM was omitted and PDN was slowly withdrawn. Overall, the treatment lasted 9 ± 1 months, range 6 to 12, and conveyed an average cumulative dose of 7.8 g of PDN and 27.5 g of CPM. Twenty-five out of 30 treated patients had complete remissions at the end of the cycle, three improved and two had minimal disease progression which subsequently stabilized. There were 10 relapses in 9 patients after an average of 52 months from the end of the cycle. All relapses were treated with a repeat cycle: nine remitted completely and one improved. The results were independent of renal histology, plasma creatinine concentration (PCr) and proteinuria. On average, PCr fell from 114 ± 82 to 88 ± 26 after treatment, and to 97 ± 26 μmol/L at the end of an average follow-up of 109 months. Urine protein excretion was 4.8 ± 0.9, 0.7 ± 0.3 and 0.5 ± 0.2 g/day. In a group of untreated patients there were no remissions, and disease progression was observed with a rise in PCr from 97 ± 17 to 221 ± 53 μmol/L at the end of an average follow up of five years; their proteinuria remained stable in the nephrotic range. We conclude that this new IS schedule is highly effective in inducing remission of MGN and in preventing its progression towards end-stage renal disease.