Ten Tips on Immunosuppression in Primary Membranous Nephropathy

Abstract

Membranous nephropathy (MN) management poses challenges, particularly in selecting appropriate immunosuppressive treatments (IST) and monitoring disease progression and complications. This manuscript highlights ten key tips for the management of primary MN based on current evidence and clinical experience. First, we advise against prescribing immunosuppressive treatment (IST) to patients without nephrotic syndrome, emphasizing the need for close monitoring of disease progression. Second, we recommend initiating IST in patients with persistent nephrotic syndrome or declining kidney function. Third, we suggest prescribing rituximab or rituximab combined with calcineurin inhibitors (CNI) in medium-risk patients. Fourth, we propose cyclophosphamide-based immunosuppression for high-risk patients. Fifth, we discourage the use of glucocorticoid monotherapy or mycophenolate mofetil as initial treatments. Sixth, we underscore the importance of preventing infectious complications in patients receiving IST. Seventh, we emphasize the need for personalized monitoring of IST by closely measuring kidney function, proteinuria, serum albumin, and anti-PLA2R levels. Eighth, we recommend a stepwise approach in the treatment of resistant disease. Ninth, we advise adjusting treatment for relapses based on individual risk profiles. Finally, we caution about the potential recurrence of MN after kidney transplantation and suggests appropriate monitoring and treatment strategies for post-transplantation MN. These tips provide comprehensive guidance for clinicians managing MN, aiming to optimize patient outcomes and minimize complications.