An overview of immunosuppressive therapy in idiopathic membranous nephropathy

Idiopathic membranous nephropathy is the most common cause of nephrotic syndrome. In patients who present with nephrotic range proteinuria the clinical course is variable, with 50% of patients developing end stage renal disease after extended follow-up without therapy. We review the various immunosuppressive treatment modalities. The efficacy of alkylating agents is demonstrated in randomized trials, although side effects are a major drawback. Calcineurin inhibitors, rituximab and possibly adrenocorticotropic hormone (ACTH) are able to induce remission of proteinuria, which portends a good prognosis. However, the efficacy of these agents must be confirmed in randomized trials with adequate renal end points. Immunosuppressive treatment should be restricted to high risk patients. The use of immunosuppressive therapy has improved outcome of patients with iMN, with nowadays less than 10% of patients progressing to end stage renal disease (ESRD).