Conservative And Immunosuppressive Therapies' Effectiveness Evaluation In Medium-risk Group Of IMN

Objective: Idiopathic membranous nephropathy(IMN)has a large prognostic difference.For patients in the medium-risk group with proteinuria of 4-8g/d,considering the side effects of immunosuppressive treatment and complications caused by the disease,how do we choose the suitable therapeutic schedule?We mainly studied the prognosis between initial conservative treatment and immunosuppressive therapy,delayed immunosuppressive therapy(initial-conservative treatment but then changed into the immunosuppressive therapy for aggravation)and immunosuppressive therapy from the start,investigated the adverse reactions associated with immunosuppressive therapy and prognostic factors of patients with initial conservative therapy,which can provide the the most optimum therapeutic schedule for IMN patients in medium-risk group.Methods: Patients with idiopathic membranous nephropathy treated in Shengjing Hospital,Southern Lake Hospital Area with paralleled renal puncture biopsy from January 1st 2012 to December 31 st 2016 were collected.The medium-risk group was screened.We excluded patients with secondary MN,inadequate laboratory data record,followed-up less than 12 months.The final follow-up time was December 31 st 2016.A total of 84 patients were enrolled.Patients with initial conservative treatment was the ICT group.Patients treated with immunosuppression were IT group.We compared the prognostic differences between the two treatment regimens.Patients with initial-conservative treatment but then changed into immunosuppressive therapy for aggravation were the DIT group.We studied whether delayed treatment had adverse effects on prognosis.Patients receiving remission by always conservative treatment were remission group(CR group).Patients failed to conservative treatment were non-remission group(NR group).NR group included patients who always been treated with conservative treatment and who had changed to immunosuppressive therapy due to exacerbation.The spontaneous remission rate of IMN in the medium-risk group and the factors affecting patients' prognosis with initial conservative therapy were analyzed.Results: A total of 84 IMN patients in the medium-risk group were enrolled.The average follow-up time was(30.67±14.7)months.There were 41 patients in ICT group.There were 15 patients in DIT group.At the study end 11 patients were in CR,3 patients were in PR,1 patient did not receive remission.26 patients were treated with conservative therapy all the time.They were CT group.11 patients achieved CR,8 patients achieved PR,7 patients did not receive remission.43 patients had been treated with corticosteroid combined with immunosuppressant.They were IT group.25 patients achieved CR,8 patients achieved PR,10 patients did not receive remission.1.ICT group and IT group had no difference in the cumulative effective rate,recurrence rate,frequency of complications,3-year e GFR reduced absolute value.But ICT group had lower complete remission rates than IT group,p=0.040.The complete remission median time of ICT group and IT group were 30 months and 20 months separately.IT group had higher adverse reaction rate than ICT group.2.DIT group and IT group had no difference in the cumulative effective rate,cumulative complete remission rate,recurrence rate,frequency of complications,and 3-year e GFR reduced absolute value.The adverse reactions caused by corticosteroid and immunosuppressor in IT group were up to 84.5%.They mainly included moon face,infection,transaminase elevation,blood pressure elevation,blood glucose elevation,and so on.3.The spontaneous remission rate of IMN in the medium-risk group was up to 46.3%.By making a comparison between CR group and NR group,patients in the CR group had lower male proportion,higher e GFR,lower cystatin C,lower total cholesterol.Through the multi-factor Logistic regression analysis,low cholesterol in initial treatment(OR=0.472,95%CI=0.244-0.914,P=0.026)was the independent protective factor for initial conservative therapy to gain remission.Conclusions: 1.There was no difference in effective rate,recurrence rate,frequency of complications,3-year e GFR reduced absolute value between initial conservative therapy and immunosuppressive therapy for IMN patients in the medium-risk group.But initial conservative therapy had lower complete remission rate than the immunosuppressive therapy.2.The delayed immunosuppressive therapy had no influence on prognosis of IMN patients in the medium risk group.The occurrence of drug adverse reactions in immunosuppressive therapy was high.Some adverse reactions were serious,such as infection.Therefore,patients with IMN in the medium-risk group could be treated with initial conservative therapy,but only with immunosuppressive therapy if their condition is aggravated.3.The spontaneous remission rate of IMN in the medium-risk group was up to 46.3%.For IMN patients in the medium risk group,low cholesterol level in initial treatment was the independent protective factor for remission.