A Cochrane review [Abstract] 1 included 65 studies on immunosuppressive treatments for idiopathic membranous nephropathy (IMN), with a total of 3807 subjects.
Combinedcorticosteroids and alkylating agents reduced death and ESKD, increased complete or partial remission and complete remission (table T1), and decreased the number of patients with doubling of serum creatinine. Immunosuppression significantly reduced all-cause mortality or risk of ESKD and risk of ESKD, increased complete or partial remission (table T2 ), and decreased the number of patients with doubling of serum creatinine. However this regimen was associated with more discontinuations or hospitalisations.
| Outcome Follow-up: 6 monthsto 12 years | Relative effect(CI) | Control = no treatment or ACEi or corticosteroids | Intervention = Alkylating agents and corticosteroids | Number of participants (trials) |
|---|---|---|---|---|
| Death | RR0.76(0.25 to 2.30) | 37/1000 | 28/1000 (9 to 84) | 440 (7) |
| End-stage kidney disease | RR 0.42(0.24 to 0.74) | 146/1000 | 61/1000 (35 to 108) | 537 (9) |
| Complete or partial remission | RR 1.37(1.04 to 1.82) | 411/1000 | 604/1000 (459 to 803) | 468 (9) |
| Outcome Follow-up: 6 months to 12 years | Relative effect(CI) | Control = no treatment or ACEi | Intervention = Immunosuppressive treatments | Number of participants (trials) |
|---|---|---|---|---|
| Death | RR 0.73(0.34 to 1.59) | 40/1000 | 30/1000 (14 to 64) | 944 (16) |
| End-stage kidney disease | RR 0.59(0.35 to 0.99) | 124/1000 | 73/1000 (43 to 123) | 944 (16) |
| Complete or partial remission | RR 1.44(1.05 to 1.97) | 337/1000 | 485/1000 (355 to 663) | 879 (16) |
A network meta-analysis 2 included 48 RCTs with 2736 patients and 13 immunosuppressive agents. Most regimens (except for leflunomide, mizoribine and steroids) showed significantly higher probabilities of total remission when compared with non-immunosuppressive therapies (the control group), with risk ratios (RRs) of 2.71 (95% CI) 1.81 to 4.06 for tacrolimus+tripterygium wilfordii, 2.16 (1.27 to 3.69) for adrenocorticotropic hormone, 2.02 (1.64 to 2.49) for tacrolimus, 2.03 (1.13 to3.64) for azathioprine, 1.91 (1.46 to 2.50) for cyclosporine, 1.86 (1.44 to2.42) for mycophenolate mofetil, 1.85 (1.52 to 2.25) for cyclophosphamide, 1.81 (1.10 to 2.98) for rituximab, 1.80 (1.38 to 2.33) for tripterygium wilfordii, 1.72 (1.35 to 2.19) for chlorambucil. The changes of serum creatinine were not significantly different between immunosuppressive agents and the control. Infection, gastrointestinal symptoms, and bone marrow suppression were the common adverse events associated with most of the immunosuppressive therapies.
Comment: The quality of evidence is downgraded by imprecise results (limited study size for each comparison) .
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