Mycophenolate Mofetil/Prednisolone Versus Methylprednisolone/Chlorambucil Treatment in Idiopathic Membranous Nephropathy Stage III-IV

Background. In 1984 Ponticelli et al. published the results of a controlled study where patients with idiopathic membranous nephropathy (IMN) and nephrotic syndrome were randomized to receive supportive therapy or to be given a six month therapy with methylprednisolone and chlorambucil alternated every other month, with significantly better outcome in treated patients. Mycophenolate mofetil (MMF) is a new immunosuppressive drug which presented some effects on the nephrotic syndrome in IMN previously resistant to steroids and cytotoxic agents. Methods. To assess whether methylprednisolone/chlorambucil or methylprednisolone/MMF may have better therapeutical index in patients with advanced IMN we compared two regimens based on a 6-mo treatment. 1) Alternating every month methylpednisolone/chlorambucil or 2) giving simultaneously methylprednisolone/MMF. The study was not randomized. Nephrotic patients with biopsy proven stage III-IV idiopathic membranous nephropathy and normal renal function were divided in two age and sex matched groups by accidental choice. 1 group patients (n=23) were given methylprednisolone 1g/i.v./daily for 3 consecutive days followed by oral steroids 0,4mg/kg/d for 27 days alternated every other month with chlorambucil 0,2mg/kg/d for 30 days. The whole treatment lasted 6 months. 2 group (n=12) received MMF 2g/d and steroids 0,4mg/kg/d for 6 months, followed by slow tapering over the steroids during the further 6 months to 20mg/d and MMF to 1,5/d. The follow-up period was one year. Results. Proteinuria in the 1 group of patients significantly decreased after 6 months (5,5+-0,58 to 1,82+-0,6g/d, p<0,05) and one year (0,74+-0,27g/d, p<0,01), with complete remission of the nephrotic syndrome in14/23, partial in 7/23 and persistent in 2/23. Proteinuria in the 2 group of patients also presented significant decrease (8,87+-2,23 to 4,51+1,01g/d, p<0,05) after 6 months, and one year (1,23+-0,26, p<0,01). Complete remission was obtained in 2/12 and partial in the other 10 patients. There was no significant difference between the two groups for the decreasing trend of proteinuria. Conclusions. We can conclude that both regimens were effective in our patients, especially steroids/MMF treatment, taking into consideration the higher degree of proteinuria at start of the treatment.