Treatment of membranous nephropathy with chronic renal insufficiency]

Several studies have suggested that, in patients with membranous nephropathy, immunosuppressive therapy is effective even when started in the presence of already established renal insufficiency. Most of the favorable results reported have been obtained with the use of cytotoxic agents given together with glucocorticoids, which produce a 70-80% reduction of proteinuria and can preserve renal function. However, patients with renal insufficiency are more exposed to the risk of side effects caused by these drugs. Since the published results have shown that the actual target of immunosuppressive agents is the nephrotic syndrome and the favorable response of renal function is always subordinate to its remission, the selection of patients who are likely to benefit from treatment should take this aspect into account. In addition, patient selection should avoid excessive costs associated with negligible benefits when biopsy-proven advanced chronic renal damage or serum creatinine above 3-4 mg/dL are present. Finally, drug dosage should be adjusted in cases of chronic renal insufficiency.