Synthetic ACTH in High Risk Patients with Idiopathic Membranous Nephropathy: A Prospective, Open Label Cohort Study

Abstract

New therapeutic agents are warranted in idiopathic membranous nephropathy. Synthetic ACTH may be advantageous with reported remission rates up to 85% and few side effects. We conducted a prospective open label cohort study from 2008 till 2010 (NCT00694863). We prospectively selected patients with idiopathic membranous nephropathy and high risk for progression (defined as βeta-2-microglobulin (β2m) excretion of >500 ng/min). For comparison, we selected matched historical controls treated with cyclophosphamide. The prospectively selected patients received intramuscular injections of synthetic ACTH during 9 months (maximal dose 1 mg twice a week). The primary endpoints concerned the feasibility and incidence of remissions as a primary event. Secondary endpoints included side effects of treatment and the incidence of remissions and relapses at long-term follow-up. Twenty patients (15 men) were included (age 54±14 years, serum creatinine 104 μmol/l [IQR 90–113], urine protein:creatinine ratio 8.7 g/10 mmol creatinine [IQR 4.3–11.1]). Seventeen patients (85%) completed treatment. 97% of injections were administered correctly. Cumulative remission rate was 55% (complete remission in 4 patients, partial remission 7 patients). In a group of historical controls treated with cyclophosphamide and steroids, 19 of 20 patients (95%) developed a remission (complete remission in 13 patients, partial remission in 6 patients) (p<0.01). The main limitation of our study is its small size and the use of a historical control group. We show that treatment with intramuscular injections of synthetic ACTH is feasible. Our data suggest that synthetic ACTH is less effective than cyclophosphamide in inducing a remission in high risk patients with idiopathic membranous nephropathy. The use of synthetic ACTH was also associated with many adverse events. Therefore, we advise against synthetic ACTH as standard treatment in membranous nephropathy.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Flowchart (algorithm) of patient inclusion.

Legend: eGFR = estimated glomerular filtration rate (by MDRD 4 equation), CI = contraindications, ACTH = synthetic ACTH, NS = nephrotic syndrome.

Fig 2. Flowchart of treatment and events during follow-up in the ACTH group.

Legend: ACTH = synthetic ACTH, CR = complete remission, PR = partial remission, PNS = persisting nephrotic syndrome, RF = renal failure, 2nd treatment = alternative immunosuppressive treatment

Fig 3. Kaplan-Meier plot for cumulative incidence of remission.

Legend: Number of patients at risk for a remission at each time point are given below the figure. Log-rank test p = 0.005. ACTH = synthetic ACTH, CP = cyclophosphamide.

Fig 4. Kaplan-Meier plot for relapse free survival.

Legend: Number of patients at each time point are given below the figure. Log-rank test p = 0.020. ACTH = ACTH, CP = cyclophosphamide.