Membranous Lupus Nephritis: The Same, But Different

Membranous lupus nephritis (MLN) has a favorable prognosis compared to proliferative lupus nephritis (PLN) or combined MLN/PLN, although a significant proportion of cases will progress to end-stage kidney disease. There is considerable morbidity associated with thrombotic complications and treatment. Nondirected care includes renin-angiotensin-aldosterone system blockade, cardiovascular risk management, and antimalarial agents. There may be a role for corticosteroid monotherapy in some patients, but this requires further investigation. Clinical trials and observational reports have led to different immunosuppression regimens for MLN, although high-grade evidence favoring a particular agent remains elusive. Established medications used in the treatment of PLN, such as mycophenolate, cyclophosphamide, and azathioprine, may also be efficacious in MLN, or at least steroid sparing. The calcineurin inhibitors appear promising as an alternative treatment in MLN, particularly with emerging experimental data supporting their nonimmunologic antiproteinuric effects. There is also emerging evidence for “multitargeted therapy” in combined MLN/PLN, although the long-term efficacy is still unproved.