Idiopathic Membranous Nephropathy:- to treat with immunosuppresion or not to treat is the question at hand.
The classic division has been via the Toronto Registry of breaking down in terms of low risk of progression, medium risk and high risk based on degrees of proteinuria.
This landmark paper just published in JASN April issue really questions the need for treatment early on.
This retrospective trial, very large set of patients showed that spontaneous remission (SR) occurred in 30% of patients; but the decline in proteinuria might take up to a year. What was more interesting is that, despite remission in the low proteinuria group, a significant number in the moderate proteinuria and 22% in the >12gm of proteinuria had SR as well.
This is different than what was previously thought. SR is not very common in patients with >12gm of proteinuria. On the other hand, this study showed the opposite and that significant amount of these patients had a SR.
From the point of a physician deciding when to start immunosuppresion in this high risk category., this study might shed some more light. Four features that defined early remission were female gender, lower proteinuria, lower serum crt and treatment with ACEI/ARB.
What this study might teach us is that:- Perhaps the first 6-9 months is a wait and watch period for that high risk >12gm group. If there is a decline by 50% in proteinuria, perhaps a SR is coming on and not to initiate immunosuppresive therapy; just continue anti proteinuria regimen like ACEI/ARB. If in those 6 months, proteinuria doesn't improve and other complications of nephrotic syndrome ensue, renal function is declining, immunosuppresive therapy might be needed.
A nice editorial is also a good read with this study. Keep in mind its still a retrospective study, but might give some answers that we didn't have for a long time.
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