Therapeutic target
- Avert deterioration of renal function
Note: If there is a normal glomerular filtration rate (GFR; total volume of primary urine produced by all glomeruli (renal corpuscles) of both kidneys combined per time) and subnephrotic proteinuria (protein < 3.5 g/day), spontaneous progression can be awaited.
Therapy recommendations
- If proteinuria (increased excretion of protein in urine) >4 g/d is still found after 6 months of supportive therapy (supportive treatment measures) or if a high-risk constellation is present, there is an indication for immunosuppressive therapy.
- Immunosuppressive therapy depending on group classification (according to renal function and existing proteinuria):
- Chlorambucil (alkylants) + methylprednisolone (glucocorticoids) + ie, therapy according to the Ponticelli scheme; duration of therapy: 6 months.
- In case of high risk (high-risk constellation) of progressive renal failure/progressive renal impairment (proteinuria > 8 g/d and/or creatinine elevation):
- Cyclophosphamide (alkylants) + methylprednisolone(glucocorticoids):
- Months 1, 3, and 5 – methylprednisolone 1,000 mg i.v. days 1-3, then prednisolone 0.5 mg/kg/d p.o. for 27 days
- Month 2, 4 and 6 – cyclophosphamide orally 2 mg/kg/d for 30 days (while controlling leukocyte count (white blood cell count), pause therapy if leukos < 3500 /µl!)
- Alternatively with ciclosporin (cyclosporin A) + glucocorticoids in contraindications (contraindications) for the Ponticelli regimen or if you want to have children.
- Cyclophosphamide (alkylants) + methylprednisolone(glucocorticoids):
- In group 1 (normal renal function, proteinuria ≤ 4 g/d), immunosuppressive therapy is omitted at baseline.
- See also under “Further therapy”.
Other therapeutic approaches
Studies currently underway include the monoclonal antibody rituximab (375 mg/m² per week, a total of 4 x or alternatively 2 x 1,000 mg at two-week intervals).
It has since been confirmed that rituximab is more likely to prevent renal corpuscle (Malpighi corpuscle) damage than the currently preferred treatment with the immunosuppressant ciclosporin. After 24 months, 39 patients (60%) had met the primary endpoint (=achieved partial or complete remission) versus only 13 patients (20%) in the ciclosporin group. Notably, the secondary end point (complete remission), defined as a renal protein loss of less than 0.3 grams per day and a serum albumin of at least 3.5 g/dL, was met at 24 months by 23 patients (35%) in the rituximab group versus none in the ciclosporin group.
