BACKGROUND AND OBJECTIVES: The long-term effect of immunosuppressive therapy (IS) on kidney survival in idiopathic membranous nephropathy (MGN) is debated. The introduction of renin angiotensin blockade, rigorous BP control, and the increasing age at presentation of patients with MGN adds further uncertainty. Given these important changes, we sought to determine whether implementation of IS has altered outcome. DESIGN, SETTING, PARTICIPANTS, & METHODS: We prospectively evaluated 280 incident MGN patients from three distinct 10-year periods starting from 1975. RESULTS: We found expected changes in treatment regimens but also variations in age, renal function, severity of proteinuria, and BP at presentation over this time. Outcomes did not differ over time if these significant variations in clinical characteristics were not accounted for across the eras. The effect of IS in the 57 patients treated with currently recommended regimens was assessed using propensity adjustment to address selection bias and the effect of newer, conservative therapies. A propensity score estimating the probability of receiving IS permitted the pairing of 39 treated patients with controls with similar high risk of progression of clinical features. Using this approach, IS was associated not only with remissions in proteinuria but also with substantially improved renal survival. CONCLUSIONS: The study confirms that patient presenting characteristics and management regimens have changed significantly over time and the natural history of MGN has been altered. A study of propensity-matched patients confirms that current recommendations for IS have improved outcomes in MGN patients at high risk of progression.
BACKGROUND AND OBJECTIVES: The long-term effect of immunosuppressive therapy (IS) on kidney survival in idiopathic membranous nephropathy (MGN) is debated. The introduction of renin angiotensin blockade, rigorous BP control, and the increasing age at presentation of patients with MGN adds further uncertainty. Given these important changes, we sought to determine whether implementation of IS has altered outcome. DESIGN, SETTING, PARTICIPANTS, & METHODS: We prospectively evaluated 280 incident MGN patients from three distinct 10-year periods starting from 1975. RESULTS: We found expected changes in treatment regimens but also variations in age, renal function, severity of proteinuria, and BP at presentation over this time. Outcomes did not differ over time if these significant variations in clinical characteristics were not accounted for across the eras. The effect of IS in the 57 patients treated with currently recommended regimens was assessed using propensity adjustment to address selection bias and the effect of newer, conservative therapies. A propensity score estimating the probability of receiving IS permitted the pairing of 39 treated patients with controls with similar high risk of progression of clinical features. Using this approach, IS was associated not only with remissions in proteinuria but also with substantially improved renal survival. CONCLUSIONS: The study confirms that patient presenting characteristics and management regimens have changed significantly over time and the natural history of MGN has been altered. A study of propensity-matched patients confirms that current recommendations for IS have improved outcomes in MGN patients at high risk of progression.
Authors: Jan A J G van den Brand; Peter R van Dijk; Julia M Hofstra; Jack F M Wetzels Journal: Clin J Am Soc Nephrol Date: 2014-05-22 Impact factor: 8.237
Authors: Andrew Howman; Tracey L Chapman; Maria M Langdon; Caroline Ferguson; Dwomoa Adu; John Feehally; Gillian J Gaskin; David R W Jayne; Donal O'Donoghue; Michael Boulton-Jones; Peter W Mathieson Journal: Lancet Date: 2013-01-09 Impact factor: 79.321