Thread by @thekidneykiddo

Rituximab in membranous nephropathy!
Quick poll - Has recent evidence changed your practice as first line therapy in membranous nephropathy?

Rituximab is crawling it’s way as part of immunotherapy in many diseases now

But does it warrant its use as 1st line therapy in all patients with MN?
Let’s see a few clinical implications:

#1. Patients with very high levels of anti-pla2r levels are less likely to respond to Rtx
Ref: pubmed.ncbi.nlm.nih.gov/29571438/

#2. What is the appropriate dose you would use?
This trial shows a higher remission with the 1g dose than the 375mg/m2 dose

#3. What about patient with worsening gfr?
Rituximab takes time for response!
Ref: supplementary appendix of the MENTOR trial
Zero patients achieve CR at 6 months!

#4. Rituximab is lost in the urine of patients with nephrotic proteinuria

Ref: sciencedirect.com/science/articl…

Hence, factors that would cause a low response to Rituximab would be:
1. High anti-pla2r levels
2. Worsening gfr
3. Heavy proteinuria
In other words, those with ‘high risk’ as mentioned in the kdigo controversies conference

And therefore - risk stratification may be quite important in the management of MN
Wonderful algorithm in the recent article in Nephron. Rituximab for low risk and cyclophosphamide for high risk
karger.com/Article/FullTe…
Must say - wonderful review article on MN!!

Also mentioned in the kdigo gn 2020 public review draft:

To conclude: There’s no ‘one-size fits all’ drug for MN
The armamentarium has just been strengthened by the addition of Vitamin R!
So choose wisely friends!

#iqraakidneyclub