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Long-term outcomes of persistent disease and relapse in primary membranous nephropathy
Durga A K Kanigicherla1,2, Colin D Short1, Stephen A Roberts3
1Manchester Institute of Nephrology and Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
Background:
Primary membranous nephropathy is associated with variable clinical course ranging from spontaneous remission to slow progression to end stage renal failure. Achieving remission confers better renal survival in primary membranous nephropathy (PMN). Longer term outcomes such as patient survival and relapse of active disease remain poorly understood.
Methods:
We performed a retrospective study of 128 consecutive adult patients diagnosed with biopsy proven PMN at a single UK centre between 1980 and 2010. These patients were followed prospectively over a median of 128 months. We assessed impact of persistent disease and relapse on Stage 5 chronic kidney disease (CKD-5) and patient survival and present longer term cumulative incidences of different end points.
Results:
One hundred patients achieved partial remission (PartRem) and 28 patients did not achieve remission (NoRem). Nine per cent of patients achieving first remission developed CKD-5 and 75% of those with NoRem developed CKD-5 [hazard ratio (HR) 0.07, 95% confidence interval 0.03-0.19). Relapse following PartRem occurred in 31 patients (31%) during follow-up and was significantly associated with progression to CKD-5. Progression to CKD-5 was strongly associated with death (47 versus 6%, HR 23.4; P < 0.01). Cumulative incidence at 15 years following first presentation included: death, 14%; CKD-5, 28%; and relapse 40% (in patients who achieved first remission).
Conclusions:
Our data strongly suggest that mortality in PMN is seen in patients with disease progression to CKD-5. Achieving remission is strongly associated with improved renal survival after first presentation and following relapse. We suggest that patients who achieve remission should be followed up in longer term, and better strategies to help improve outcomes are needed in clinical practice.
Insights
Achieving remission in primary membranous nephropathy (PMN) significantly improves kidney survival and reduces mortality. Relapses are common and linked to worse outcomes, highlighting the need for long-term patient follow-up.
Area of Science:
- Nephrology
- Immunology
- Internal Medicine
Background:
- Primary membranous nephropathy (PMN) has a variable clinical course.
- Remission is key for better renal survival in PMN.
- Long-term outcomes like patient survival and disease relapse in PMN are not well understood.
Purpose of the Study:
- To assess the long-term outcomes of primary membranous nephropathy.
- To evaluate the impact of disease remission and relapse on renal survival and patient survival.
- To determine cumulative incidences of key endpoints in PMN patients.
Main Methods:
- Retrospective study of 128 adult patients with biopsy-proven PMN.
- Prospective follow-up for a median of 128 months.
- Assessment of remission, relapse, Stage 5 chronic kidney disease (CKD-5), and patient survival.
Main Results:
- 100 patients achieved partial remission (PartRem), 28 did not (NoRem).
- 9% of PartRem patients developed CKD-5 vs. 75% of NoRem patients.
- 31% of PartRem patients relapsed, associated with CKD-5 progression; CKD-5 strongly predicted mortality.
Conclusions:
- Mortality in PMN is linked to progression to CKD-5.
- Achieving remission significantly improves renal survival post-presentation and post-relapse.
- Long-term follow-up for patients achieving remission is recommended, with a need for improved clinical strategies.
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