A difficult trade off for adults with membranous nephropathyBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f248 (Published 16 January 2013) Cite this as: BMJ 2013;346:f248
Immunosuppression is an established but controversial treatment for patients with idiopathic membranous nephropathy. Supporting evidence is patchy, particularly for the minority of patients with worsening renal function. A new trial reports that the combination of chlorambucil and prednisolone does slow the decline more effectively than supportive care alone, but side effects were common and potentially serious⇑.
Recruitment was slow, and the trial relatively small, with just 108 patients randomised over three arms. Patients given six months of chlorambucil and prednisolone did best during three years of follow-up, although 19 of 33 still had further substantial reductions in glomerular filtration rate. Renal function declined by at least 20% in 29 of the 36 patients given ciclosporin and 31 of 37 patients managed with supportive care alone. Ciclosporin looked ineffective, and the authors suggest that renal physicians avoid it.
Both active treatments caused serious side effects. Haematological problems such as neutropenia were particularly common in participants given chlorambucil and prednisolone (28/33); eight developed glucose intolerance, and two developed cancer.
The authors plan longer follow-up to track side effects and end stage renal disease. Meanwhile, renal doctors and their patients will have to decide whether the combination of chlorambucil and prednisolone works well enough to justify the substantial risk of harm, says a linked comment (doi:10.1016/S0140-6736(12)62033-9).
Cite this as: BMJ 2013;346:f248