Controversies in the treatment of idiopathic membranous nephropathy

Abstract

The nephrologist must consider several difficult questions when faced with a patient who has a new diagnosis of idiopathic membranous nephropathy (IMN). Here, authors from the National Institutes of Health corral the latest trial data to provide an update on the 'who', 'when' and 'how' of IMN treatment. They focus particularly on agents that have been studied as alternatives to cytotoxic drugs and ciclosporin, including mycophenolate mofetil, rituximab and adrenocorticotropic hormone. Optimum treatment of idiopathic membranous nephropathy is both controversial and challenging. The most extensively studied and frequently used immunosuppressive regimens for this disease comprise alkylating agents plus corticosteroids or ciclosporin. All of these treatment options have inherent problems: they are not effective in all patients, partial—rather than complete—remissions are common, adverse effects are worrisome, and relapses after treatment cessation remain problematic. Alternative immunosuppressive agents have been tested in an effort to overcome these unresolved issues. This paper reviews the available evidence regarding both established and new agents for the treatment of patients with idiopathic membranous nephropathy, with an emphasis on the results of the most recent clinical trials.