Thread by @kdjhaveri

Short Tweetorial from my talk on Membranous Nephropathy: 2021 Update: #glomerular disease
1. Three types of Membranous- Primary, Secondary and Allo-immune

2. Causes of secondary MN: Cancers, Drugs, Infections and autoimmune disease( like any other disease).

3. Class switching happens: be-aware

4. A positive anti-PLA2R antibody test is “virtually” diagnostic of a lesion of MN (but may not always be able to reliably distinguish primary and secondary forms)

5) What will MN look like in 2022 @SethiRenalPath @RandyLucianoMD

6) Pathophysiology of MN

7) Pathophysiology of Secondary MN

8) Prognosis is unfavorable if Black race, age > 65 yr, Male, p/crt >8gm/dl >6mo, High BP/low GFR/ low Palb, Severe IFTA/FSGS, High aPLA2R ab titer, No remission with initial treatment

9) The role of PLA2R has evolved from just being diagnostic to prognostic and even following the disease

10). When do we do kidney biopsies and when do we do anticoagulation? @goKDIGO

11) Treatment summary:
Alkylating agents – best proven treatment
CNI- higher relapses
MENTOR trial( Rituximab vs CNI) and STARMEN study( tacrolimus and rituximab vs modified Ponticelli regimen) and Ri-CYCLO( Modified Ponticelli vs rituximab)

12) Evidence of Treatment
Steroids alone- Ineffective ( 1A)
Alkylating agents + Steroids- Effective for CR/PR and for preventing ESRD (1A)
Rituximab- Appears highly effective in RCT studies (1A)
Calcineurin inhibitors ± Steroids (CsA/Tac)Effective for PR; High relapse rate

13)Azathioprine + Steroids- Ineffective
Mycophenolate mofetil (MMF)- data is poor
Natural ACTH- No RCT, no long-term studies. Relapse rate uncertain
Sirolimus- limited data- not recommended

14) The cyclophosphamide in the new era
@vjha126 @JASN_News jasn.asnjournals.org/content/18/6/1…

15) Enter Rituximab pubmed.ncbi.nlm.nih.gov/27352623/

16) MENTOR- Ritux vs CNI nejm.org/doi/full/10.10…
1. RTX non inferior to CNI at 12 months
2. RTX superior at 24 months

17) Tacro_RTX combo vs Cyclical therapy( classic)
STARMEN TRIAL kidney-international.org/article/S0085-…

18) Ri-CYCLO trial- Cyclical vs Rituximab

19) what we have learned:
OLD IS GOLD( cyclo steroids cyclical therapy works and side effect profile not that bad as we thought)
PATIENT IS VIRTUE( give rituximab time to work)

20) Relapsing and Resistant diseases-- don't forget to look for secondary causes also... @goKDIGO

21) and here comes Obi @fervenzafernan1

22) What future looks for MN @eugelin06 @KidneyNews

23) final slide summary @threader_app unroll

Interesting combo treatment option ajkd.org/article/S0272-… Combination of Rituximab, Low-dose Cyclophosphamide, and Prednisone for Primary Membranous Nephropathy @AJKDonline