Table 6.

Summary of the most common IST protocols for treating patients with primary membranous nephropathy (56–60,93)

IST RegimenDrug, DoseComments
Cytotoxic drugsKDIGO first choice
 Modified PonticelliMonths 1, 3, 5: 1 g methylprednisolone iv on days 1, 2, and 3 followed by oral prednisone, 0.5 mg/kg daily for 27 dMonitor Uprotein and WBC weekly ×8, then every 2 mo; daily oral prednisone and cyclophosphamide may have similar efficacy. Increased risk of malignancy above 36 g
Months 2, 4, 6: 2.0–2.5 mg/kg oral cyclophosphamide dailyRelapse rate 20%–30%
 Dutch protocolMonths 1, 3, 5: 1 g MP days 1–3 followed by oral prednisone, 0.5–1.0 mg/kg for 6 mo, then taperSame as above
Oral cyclophosphamide, 1.5–2.0 mg/kg daily for 12 mo
CNIsKDIGO second choice
 Cyclosporin3.5–5.0 mg/kg daily in divided doses adjusted to level of 120–200 μg/L for 12–18 mo and taperedUsed in patients resistant to cytotoxic drugs but can be used as initial therapy. Taper slowly
Prednisone 5–10 mg daily or alt daysDiscontinue at 6 mo if no response
Relapse rate 40%–50%
 Tacrolimus0.05–0.075 mg/kg daily in two divided doses adjusted to level of 3–5 μg/L for 12–18 mo and taper slowlySame as above
Prednisone 5–10 mg/kg per day daily or alt daysPreferable in young women
B cell depletionUsed for patients resistant to cytotoxic drugs or CNIs
Utility as initial therapy not yet established by RCTs
 Rituximab375 mg/M2 weekly times 4Follow CD20 counts and repeat dose if counts rise before remission in proteinuria or relapse occurs
375 mg/M2 once and follow CD20 counts
1000 mg on days 1 and 15
ACTH
 Tetracosactrin (Synacthen) (synthetic)1 mg IM every 2 wk for 6–12 mo
 Corticotropin (ACTHAR) (purified)80 U IM every 2 wk for 6–12 mo
  • IST, immunosuppressive therapy; KDIGO, Kidney Disease Improving Global Outcomes; WBC, white blood cells; MP, methylprednisolone; CNI, calcineurin inhibitor; alt, alternate; RCT, randomized controlled trial; ACTH, adrenocorticotrophic hormone; IM, intramuscular.