Ask the Experts - Renal Transplant Recipients With Membranous...
A 32-year-old man known to suffer from membranous nephropathy had a cadaver kidney transplant 10 years ago. His kidney function is normal with a serum creatinine of 1.3 mg/dL. Several months ago he developed massive proteinuria (up to 6 g/day). His kidney biopsy showed membranous nephropathy with otherwise normal-appearing glomeruli and tubulointerstitium. He is being treated with cyclosporine, mycophenolate mofetil, prednisone, and an angiotensin-converting enzyme inhibitor.

Do you recommend any additional treatment for his membranous nephropathy? What about using the Ponticelli protocol with corticosteroids and chlorambucil or cyclophosphamide?

We have no experience with the Ponticelli protocol, but in a patient who has been on immunosuppression for 10 years, I would be apprehensive about initiating a protocol that dramatically increases the degree of immunosuppression with such powerful agents as chlorambucil or cyclophosphamide. I am not aware of data suggesting that this would be effective in renal transplant recipients, and would be concerned about the risk of opportunistic infections related to overimmunosuppression. If the patient's renal function were stable, I would treat the proteinuria as you are doing. The progression of recurrent disease may be fairly slow.