Q J Med 2004; 97: 353-360
QJM vol. 97 no. 6 © Association of Physicians 2004; all rights reserved.
Restrictive use of immunosuppressive treatment in patients with idiopathic membranous nephropathy: high renal survival in a large patient cohort
From the 1Department of Nephrology, University Medical Center St. Radboud, Nijmegen, 2Internal Medicine, Amphia Hospital, Breda, 3Internal Medicine, Hospital Gelderse Vallei, Ede, 4Internal Medicine, Jeroen Bosch Center, ‘s Hertogenbosch, 5Internal Medicine, Maxima Medical Center, Veldhoven, 6Internal Medicine, Laurentius Hospital, Roermond, and 7Internal Medicine, Franciscus Hospital, Roosendaal, The Netherlands. *See Acknowledgements for study participants
Received 17 November 2003 and in revised form 23 February 2004
Background: Immunosuppressive treatment initiated at an early stage in patients with idiopathic membranous nephropathy (iMN) improves renal survival. Treatment should ideally be restricted to high-risk patients.
Aim: To evaluate the efficacy of a restrictive immunosuppressive treatment strategy for patients with iMN.
Design: Prospective cohort study evaluating a predefined treatment protocol.
Methods: From 1988, we adopted a restrictive treatment strategy: immunosuppressive treatment, mainly consisting of cyclophosphamide and steroids, was advised only in patients with renal insufficiency or severe intolerable nephrotic syndrome. We evaluated this strategy in a large patient cohort. To exclude any bias, we included all adult patients with iMN biopsied in the study period with a serum creatinine (Scr) < 135 µmol/l, a proteinuria 
3.0 g/day and/or a serum albumin (Salb) 
30 g/l at the time of biopsy. Analysis was according to the intention-to-treat principle.
Results: We studied 69 patients. At the time of biopsy, mean age was 51 years, Scr 90 µmol/l, Salb 23 g/l and proteinuria 6.7 g/day. Average follow-up was 5.5 years. Thus far 33 (48%) patients have received immunosuppressive therapy, mainly because of renal insufficiency (n = 24). Status at the end of follow-up was: complete remission n = 22 (32%), partial remission n = 24 (35%), nephrotic syndrome n = 15 (22%), persistent proteinuria n = 1 (1.4%), ESRD n = 6 (8.7%), death n = 1 (1.4%; due to bladder carcinoma after cyclophosphamide therapy). Patient survival was 100% at 5 and 7 years. Renal survival was 94% at 5 years and 88% at 7 years.
Discussion: In patients with iMN, a restrictive treatment policy assures a favourable prognosis, while preventing exposure to immunosuppressive therapy in >50% of the patients.
Address correspondence to: Dr P.W.G. du Buf-Vereijken, UMC St. Radboud, Department of Nephrology, PO Box 9101, 6500 HB Nijmegen, The Netherlands. e-mail: p.dubuf{at}nier.umcn.nl
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