Risk stratification guided treatment and outcomes of pediatric membranous nephropathy

Pediatric membranous nephropathy (MN) is a rare glomerular disease with limited data available. This single-center study aims to describe risk stratification-based treatment and its outcomes.

This retrospective observational study included children younger than 18 years of age with primary MN diagnosed from July, 2021 to December, 2024. KDIGO risk stratification criteria were modified with author consensus for pediatric thresholds, and children were stratified into low, moderate, high and very high risk. Immunosuppressive drugs included calcineurin inhibitors (CNIs), cyclophosphamide (CYC) and rituximab (RTX). Outcomes included complete remission, partial remission, no response, relapse, and decline in kidney function at 12 months and last follow-up, and were summarized across baseline risk categories and initial treatment groups. Time to first complete or partial remission was assessed using Kaplan-Meier analysis and compared using the log-rank test.

Thirty-three children were included with a mean age of 11.15 ± 3.16 years, of whom 24 (73%) were males. Baseline risk stratification showed 24 (73%) were in the high-risk category. Initially, CNIs were administered in 17 (51.5%), while CYC and RTX in 5 (15%) and 3 (9%) patients, respectively. Among high-risk patients, non-response was observed in 8 (34%) at 12 months and 4 (17%) at last follow-up. Anti-PLA2R positivity was associated with better outcomes, with higher rates of complete or partial remission (p = 0.03). At last follow-up, 4 (12.1%) children demonstrated decline in kidney function.

We describe treatment allocation and short-term outcomes in pediatric MN using a modified risk stratification-based approach. Higher risk categories appeared to have less favorable responses, while anti-PLA2R positivity was associated with better outcomes.