ACTH for membranous nephropathy

Once you go beyond the modified Ponticelli, the treatment of idiopathic membranous feels like hunting in the woods. I have a woman in her late thirties who I have been treating for almost three years. She has between 6 and 10 grams of proteinuria, no renal failure (Cr or 0.8 and stable) no hypertension, and a middling albumin with terrible lipids. She doesn't get much edema and is able to limit her use of loop diuretics to very occasionally.

We started with conservative therapy for 6 months to see where the proteinuria is going. After that we decided to give treatment a try because of the heavy proteinuria. She also had high levels of urinary IgG and urine beta-microglobulin.

She was reluctant to use cyclophosphamide because of concerns about future fertility. And I'm reluctant to use it in a young patient especially for a disease which is causing her minimal problems right now.

We started with MMF. Little effect.

We then gave a trial of CSA. Little effect.

We gave a trial of Pentoxifylline (Trental). little effect

What now? Tacro? Rituximab?

Anyone have any experience with ACTH?


I must say I have been seduced by the preliminary data (case series, rct) on ACTH. To me it looks more compelling than the alternatives (rituximab and tacro). The fact you have to go to a specialty pharmacy to get the stuff is a little intimidating.

Link to a description of membranous nephropathy from a lecture I give on Hep B, C and HIV associated renal pathology.

Renal Vitamins

Just saw this post on the Renal Fellow's Network. I appreciate his flippant attitude toward renal vitamins as they are so routine as to invite disregard but they may have an effect on mortality.

This 2004 article based on the DOPPS database shows a significant reduction in mortality (RR 0.84) associated with use of water soluble vitamins.


I always have a healthy skepticism for DOPPS data as they have been on the wrong side of the anemia, Kt/V and statin debate. Each time being refuted by the RCT. But I'll take the position that since no one will ever do a randomized controlled trial we should go forward with the renal vitamins.

I first heard about this data on renal vitamins during the at the Easterling Lecture given by Eric Young for the Michigan NKF in 2003. At the time this was explained by the reduction of homocysteine induced by the folate in the vitamin. Since that has also fallen to the blade of the RCT, I wonder what componant of the renal vitamin explains the benefit.

CKD in the NYT

Kidney Disease a Takes a Growing Toll

Nice article on the increasing prevelance of chronic kidney disease. They even mention the controversy of geriatric CKD, one of my newest interests.

The article mentions the NKF of Michigan's project to raise awareness of CKD by using hair dressers. I am the newest member of the NKF of Michigan's Scientific Advisory Board.

Also the article has a quote by Steven Fadem, a nephrologist I shared a limo with last week at the EVOLVE Primary Investigator's Meeting. Crazy small world.

MBD and Clinical Practice

Glen Chertow on MBD and clinical practice.

Starts with the high mortality of CVD in ESRD slide shown at every gatheriong of nephrologists.

MBD as a non-traditional risk factor for CVD

HEMO, 4D, Wrone on homocysteine, D-COR all RCT, All negative. [should add correction of anemia study]

45% drop out in D-COR lead to a loss of power and contributed to negative trial.

Cinacalcet approved based on its ability to get the PTH down and get patient to guidelines but we are missing the information on whether this helps patients.

Power is the probablity of detecting the treatment affect if it really exists. 90% power means that 9 out of 10 times you will detect a treatment effect if it exists.

With 3883 patients EVOLVE had 88% power to detect 20% reduction in cardiovascular disease. If the benefit is 15%, which would phenomenally important to our patients, we may not be able to detect it.