A Study of Treatment in Adult Patients with Idiopathic Membranous glomerulonephritis / 대한내과학회지

OBJECTIVE: We aimed to compare efficacy of treatment between steroid therapy and steroid-chlorambucil combination therapy in patients with adult-onset idiopathic membranous glomerulonephritis (MN). METHODS: A series of 31 biopsy-proved idiopathic MN patients was analyzed retrospectively to estimate effect of treatment with steroid and/or cytotoxic agent. All patients (male 15, female 16, mean age of 37 years old) presented a full-blown nephrotic syndrome (proteinuria >3.0gm/day, serum albumin <3.0mg/dL, edema) at the initiation of treatment and were observed for at least 6 months (mean follow up period: 28 +/- 23 months). Clinical and laboratory information were obtained at the time of presentation and at last follow up. Each patient was assigned to one of the following protacols. 1) Steroid therapy prednisolone 40 or 60mg/day (single dose) for 16 weeks. 2) Steroid-Chlorambucil combination therapy: for 6 months with three cycles of methylprednisolone pulse therapy (lgm 1V for 3 days), prednisolone 0.5mg/kg/day for 27 days, then chlorambucil 0.2mg/kg/day for 28 days. 3. Cyclophosphamide 2mg/kg/day for 28 days. RESULTS: 1) Final status in total 31 cases irrespective of therapeutic modality were complete remission in 5 (16%) cases, partial remission in 9 (29%) cases, no response in 12 (41%) cases, spontaneous complete remission in 1 cases, and spontaneous partial remission in 1 case. 2) After initial steroid therapy (in 25 cases), We observed no response in 17 (68%) case, partial remission in 3 (12%) cases, complete remission in 3 (12%) cases, and spontaneous partial remission in 2 (8%) cases. 3) The combination therapy (steroid and chlorambucil) tried in 10 cases results in 5 (50%) cases of partial remission, 2 (20%) cases of complete remission, 1 (10%) case of spontaneous partial remission, and 2 (20%) cases of no response. 4) During follow up period, renal functional deterioration was absent in any case and final albumin levels were significantly increased (p<0.05). CONCLUSION: Steroid-chlorambucil combination protocol is considered to be a more effective treatment with higher rate of overall remission compared to steroid therapy. Idiopathic MN itself seems to have a relatively benign course when considering that renal function was preserved in all cases without progression to chronic renal failure and that a few cases of spontaneous remission could be observed. For the limitation in number of cases and duration of follow up in this study, it needs prospective controlled study of more larger scale with long-term follow up to get a more reliable results.

A Clinico-pathologic Correlation in Lupus Nephritis / 대한신장학회잡지

We evaluated the relationship between the clinical and pathologic characteristics in 37 patients with biopsy-proven lupus nephritis. The peak age at onset of the disease was in the 3rd(40.5%) and 4th(32.4%) decades. The male to female ratio was 1 : 8.3. According to the WHO classification, 18 patients(48.6%) were belonged to class IV, 11 patients(29.7%) to class V and 8 patients(21.6%) to class III. At initial evaluation, nephrotic syndrome was observed in 5 patients(62.5%) of class III, 10 patients(55.6%) of class IV, and 3 patients(27.3%) of class V. The hypertension was observed 11 patients (29.7%), among which 7 (38.9%) was belonged to class IV. In patients of class III, IV and V, the mean serum creatinine was within normal limit at initial evaluation, and it was not significant difference at final study. On biopsy, the occurance of anti-DNA antibody and ANA was 63.9% and 89.2%, retrospectively. In 28 patients who were followed for more than 6 months, patients with class III and class V could be managed effectively with oral steroid only, but those with class IV lesion required steroid pulse or oral cyclophosphamide therapy. Interestingly, complete remission was obtained in 4/15 patients(26.7%) of class IV, but none with class III or V. Death had occurred in 3 patients (2 in class IV and 1 in class V). The cause of death was extrarenal complication such as infection and vascular disease. In conclusion, the patients with class IV lupus nephritis showed higher serum creatinine level although not significant, higher incidence of hypertension and progression of chronic renal failure than the other classes. Though the patients with class IV needed for more aggressive treatment with steroid pulse or cyclophosphamide-steroid combination. Thus it is suggested that the improvement of proteinuria and clinical course is possible with careful immunosuppressive therapy in selected cases of class IV lupus nephritis.