A Cochrane review included 39 studies on immunosuppressive treatments for idiopathic membranous nephropathy (IMN), with a total of 1825 subjects.
Combined corticosteroids and alkylating agents significantly reduced death or risk of ESKD and ESKD, increased complete or partial remission and complete remission (table ), and decreased proteinuria ((6 studies, 279 patients): MD -1.25 g/24 h, 95% CI -1.93 to -0.57; 6 trials, n=279) at the end of follow-up (range 9 to 120 months). Immunosuppression significantly reduced all-cause mortality or risk of ESKD and risk of ESKD, increased complete or partial remission (table ), and decreased proteinuria at the end of follow-up (range 6 to 120 months). However this regimen was associated with more discontinuations or hospitalisations (RR 5.35, 95% CI 2.19 to 13.02; 16 studies, n=880). Cyclophosphamide was safer than chlorambucil (RR 0.48, 95% CI 0.26 to 0.90; 3 studies, n=147 patients). There was no clear evidence to support the use of either corticosteroid or alkylating agent monotherapy. Cyclosporine and mycophenolate mofetil failed to show superiority over alkylating agents. Tacrolimus and adrenocorticotropic hormone significantly reduced proteinuria. The numbers of corresponding studies related to tacrolimus, mycophenolate mofetil, adrenocorticotropic hormone, azathioprine, mizoribine, and Tripterygium wilfordii are still too sparse to draw final conclusions.
| Outcome Follow-up: 9 to 120 months | Relative effect (CI) | Control = no treatment or ACEi or corticosteroids | Intervention = Alkylating agents and corticosteroids | Number of participants (trials) |
|---|---|---|---|---|
| Death or end-stage kidney disease | RR 0.44 (0.26 to 0.75) | 181/1000 | 80/1000 (47 to 136) | 488 (8) |
| End-stage kidney disease | RR 0.45 (0.25 to 0.81) | 150/1000 | 68/1000 (38 to 122) | 488 (8) |
| Complete or partial remission | RR 1.46 (1.13 to 1.89) | 408/1000 | 597/1000 (462 to 722) | 422 (7) |
| Outcome Follow-up: 6 to 120 months | Relative effect (CI) | Control = no treatment or ACEi | Intervention = Immunosuppressive treatments | Number of participants (trials) |
|---|---|---|---|---|
| Death or end-stage kidney disease | RR 0.58 (0.36 to 0.95) | 167/1000 | 97/1000 (60 to 159) | 791 (15) |
| End-stage kidney disease | RR 0.55 (0.31 to 0.95) | 125/1000 | 69/1000 (39 to 119) | 791 (15) |
| Complete or partial remission | RR 1.31 (1.01 to 1.70) | 296/1000 | 388/1000 (299 to 504) | 864 (16) |
Comment: The quality of evidence is downgraded by imprecise results (limited study size for each comparison) .