[Treatment of idiopathic membranous nephropathy. Is the anti-CD20 antibody rituximab a reasonable option?].

Abstract

BACKGROUND:

Membranous nephropathy (MN) is characterized by proteinuria and other symptoms of the nephrotic syndrome. In many cases, the etiology is unknown. Whether and how to treat MN is still a controversial question. Despite the use of corticosteroids and alkylating agents, up to 40% of patients still progress to end-stage renal failure.

CASE REPORT:

A 40-year-old male patient with biopsy-proven idiopathic MN was initially treated with prednisolone and chlorambucil because of a proteinuria of 22 g/d. Treatment with cyclosporine was started because the nephrotic syndrome failed to improve. Proteinuria was reduced to a minimum of 4 g/d. Cyclosporine was stopped after 17 months leading to a fast relapse. Therapy with an ACE inhibitor and AT(1) receptor antagonist and retreatment with cyclosporine improved proteinuria. Cyclosporine was terminated after a total of 24 months. 5 months later, relapse occurred with a high proteinuria of 34 g/d. The monoclonal anti-CD20 antibody rituximab (375 mg/m(2)) was given four times every 4 weeks. 4 weeks and 4 months after the end of treatment, proteinuria decreased to 780 mg/d and <150 mg/d, but renal function remained impaired (creatinine clearance 65 ml/min, stage 2 according to K/DOQI). Now, remission of proteinuria (<150 mg/d) has been stable for almost 2 years. However, renal insufficiency progressed further (creatinine clearance 45 ml/min, stage 3 according to K/DOQI).

CONCLUSION:

Rituximab offers the possibility for a targeted treatment of idiopathic MN. Based on the existing evidence and experience from this case, rituximab can be recommended as a new treatment option for MN, possibly before starting any treatment with cytotoxic agents and high-dose prednisolone carrying the risk of severe side effects. However, long-term results of this treatment are still lacking.

• Authors: Martin Busch, Jens Gerth, Undine Ott, Andre Schip, Christoph C Haufe, Hermann-Josef Gröne, Gunter Wolf
• Journal: Medizinische Klinik (Munich, Germany : 1983) (Med Klin (Munich)) Vol. 103 Issue 7 Pg. 519-24 (Jul 15 2008) ISSN: 0723-5003 [Print] Germany
• Vernacular Title: Behandlung der idiopathischen membranösen Glomerulonephritis. Ist der Anti-CD20-Antikörper Rituximab eine sinnvolle Therapieoption?
• PMID: 18604487 (Publication Type: Case Reports, English Abstract, Journal Article)

Chemical References

• Antibodies, Monoclonal
• Antibodies, Monoclonal, Murine-Derived
• Immunoglobulin A
• Immunologic Factors
• Immunosuppressive Agents
• Rituximab

Topics

• Adult
• Antibodies, Monoclonal (adverse effects, therapeutic use)
• Antibodies, Monoclonal, Murine-Derived
• Biopsy
• Drug Resistance
• Drug Therapy, Combination
• Glomerular Basement Membrane (pathology)
• Glomerulonephritis, Membranous (diagnosis, drug therapy, etiology, pathology)
• Humans
• Immunoglobulin A
• Immunologic Factors (adverse effects, therapeutic use)
• Immunosuppressive Agents (adverse effects, therapeutic use)
• Kidney Function Tests
• Kidney Glomerulus (pathology)
• Male
• Rituximab