Ten tips on immunosuppression in primary membranous nephropathy

Area of Science:

• Nephrology
• Immunology
• Internal Medicine

Background:

• Membranous nephropathy (MN) management presents significant challenges in treatment selection and disease monitoring.
• Optimizing immunosuppressive therapy (IST) and preventing complications are crucial for patient outcomes.

Purpose of the Study:

• To provide 10 evidence-based clinical tips for managing primary membranous nephropathy (MN).
• To guide clinicians in selecting appropriate immunosuppressive treatments (IST) and monitoring disease progression.
• To enhance patient outcomes and minimize complications associated with MN.

Main Methods:

• Review of current evidence and clinical experience in primary MN management.
• Development of 10 key recommendations for IST selection, monitoring, and complication prevention.
• Consideration of risk stratification, treatment resistance, relapses, and post-transplantation recurrence.

Main Results:

• Recommendations include avoiding IST in non-nephrotic patients, initiating IST for persistent nephrotic syndrome or declining kidney function.
• Specific IST suggestions: rituximab (RTX) or RTX plus calcineurin inhibitors for medium-risk, cyclophosphamide for high-risk patients.
• Discourages initial glucocorticoid monotherapy or mycophenolate mofetil; emphasizes infection prevention and personalized monitoring (kidney function, proteinuria, albumin, anti-PLA2R levels).

Conclusions:

• Provides a comprehensive framework for managing primary MN, including strategies for resistant disease and relapses.
• Highlights the importance of tailored monitoring and treatment adjustments based on individual risk profiles.
• Addresses the management of post-transplantation MN recurrence, offering monitoring and treatment guidance.