RESUMEN
BACKGROUND: Relapse or worsening of nephrotic syndrome (NS) in idiopathic membranous nephropathy (IMN) is generally assumed to be due to recurrent disease. Here we document that often that may not be the case. SUBJECTS AND METHODS: This is a prospective study of 7 consecutive IMN patients whose renal status improved, then worsened after completing a course of immunosuppressive therapy. Each underwent detailed testing and repeat kidney biopsy. RESULTS: In 4 patients (group A), the biopsy showed recurrent IMN (fresh subepithelial deposits). Immunosuppressive therapy was begun. In the other 3 patients (group B), the biopsy showed that the deposits had been eradicated. However, the glomerular basement membrane (GBM) was thickened and vacuolated. Immunosuppressive therapy was withheld. Groups A and B were comparable except that group B had very high intakes of salt and protein, based on 24-hour urine testing. Reducing their high salt intake sharply lowered proteinuria to the subnephrotic range and serum creatinine stabilized. CONCLUSION: This work is the first to demonstrate that relapse/worsening of NS can occur in IMN even though the GBM deposits have been eradicated. High salt and protein intake in combination with thickened and vacuolated GBM appears to be the mechanism.
Asunto(s)
Progresión de la Enfermedad , Glomerulonefritis Membranosa/patología , Glomérulos Renales/patología , Síndrome Nefrótico/etiología , Adulto , Anciano , Creatinina/sangre , Proteínas en la Dieta/efectos adversos , Glomerulonefritis Membranosa/complicaciones , Glomerulonefritis Membranosa/tratamiento farmacológico , Humanos , Inmunosupresores/uso terapéutico , Glomérulos Renales/inmunología , Masculino , Persona de Mediana Edad , Síndrome Nefrótico/dietoterapia , Estudios Prospectivos , Proteinuria/etiología , Recurrencia , Sodio/orina , Cloruro de Sodio Dietético/efectos adversosRESUMEN
We report 4 consecutive adult patients with steroid-responsive frequently relapsing minimal change disease (MCD) who continued to experience relapse after 1 to 4 courses of cyclophosphamide therapy. Each patient then was administered mycophenolate mofetil (MMF) and prednisone in tapering doses. This therapy was followed by sustained remission and is being well tolerated. MMF is promising therapy in frequently relapsing MCD, even in those with disease that continued to relapse after cyclophosphamide therapy. A controlled clinical trial of MMF therapy in this disorder is warranted.