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Kidney Week

Abstract: PO1775

Suboptimal Serological and Clinical Remission on Supportive Therapy in Phospholipase A2 Receptor Membranous Nephropathy

Session Information

Category: Glomerular Diseases

  • 1202 Glomerular Diseases: Immunology and Inflammation

Authors

  • Pham, Jennifer A., Ochsner Health System, New Orleans, Louisiana, United States
  • Velez, Juan Carlos Q., Ochsner Health System, New Orleans, Louisiana, United States

Group or Team Name

  • Ochsner Nephrology
Background

A traditional notion is that one third of patients with primary membranous nephropathy (MN) are expected to achieve spontaneous clinical remission without immunosuppressive therapy (IST). Thus, Kidney Disease Improving Global Outcomes (KDIGO) recommends at least 6 months of supportive therapy (SUPPT) without IST in patients with primary MN with low risk for developing end-stage renal disease. Recently, phospholipase A2 receptor (anti-PLA2R) antibody titers have been added to decision-making algorithms. Our objective was to examine and contrast the rates of serological and clinical remission in patients with PLA2R-MN managed by either SUPPT or IST.

Methods

We retrospectively reviewed records of adult patients diagnosed with PLA2R-MN in native kidneys over the last 5 years at our single medical center. Trajectories of anti-PLA2R titers were extracted. Rates of partial remission (PR) (reduction in urine protein-to-creatinine ratio (UPCR) to 0.5 to 3.0 g/g) and complete remission (CR) (UPCR < 0.5 g/g) were assessed at varying time points within a 24 month interval and compared between patients managed by either SUPPT or IST.

Results

We included 25 patients, median age 59 years, 44% women, 60% black. Positive PLA2R antigen in kidney biopsy was verified in 18/27 (72%). Eight patients were managed by SUPPT and 17 by IST. The median serum creatinine at the time of biopsy was 1.0 mg/dL for both groups (p=0.58), whereas the median UPCR were 5.6 g/g in the SUPPT arm and 10.5 g/g for IST (p=0.004). Median anti-PLA2R titer at baseline were 49 (17-76) and 258 (35 - >1500) RU/mL for the SUPPT and IST arms, respectively, p=0.0058. By the 18-month time mark, 9/17 (53%) in the IST group achieved serologic remission (negative anti-PLA2R titer) vs 0/6 (0%) in the SUPPT arm (p=0.02) (missing follow up anti-PLA2R titer in 2 SUPPT patients). At 24 months, CR and PR was achieved in 1/8 (12.5%) and 3/8 (37.5%) of patients under SUPPT and in 3/17 (17.6%) and 8/17 (47%) of those under IST (p=0.75 and p=0.66, respectively).

Conclusion

Despite baseline characteristics denoting less aggressive disease, patients with PLA2R-MN under SUPPT therapy did not achieve greater rates of clinical remission and exhibited a lower rate of serological remission. Current algorithms dictating choice of SUPPT as initial treatment in low-risk PLA2R-MN should be revisited.