Dr. Anna-Lena Berg (AB), from Department of Nephrology, Lund University, discusses her abstract for the National Kidney Foundation’s 2014 Spring Clinical Meetings (SCM14), Nephrotic Patients with Membranous Nephropathy (MN) Treated with ACTH: Five Year Follow-Up, with Dr. Kenar Jhaveri (eAJKD), eAJKD Editor.
eAJKD: Why don’t you tell us a little about your research and abstract being presented at NKF 2014 Spring Meetings?
AB: In 1994, we noticed that ACTH at pharmacological dosage had a considerable lipid-lowering effect (see Berg & Nilsson-Ehle and Rafnsson et al). We found the same effect on lipid metabolism in patient groups with various lipid disorders (see Berg & Nilsson-Ehle; Arnadottir et al; Hardarson et al). In one of the follow-up studies of the ACTH-specific lipid-lowering effect, we also accidentally found an ACTH-specific antiproteinuric effect in patients with membranous nephropathy (MN) (Berg et al). In nephrotic patients with idiopathic membranous nephropathy we observed that after 2 months of ACTH treatment, the urinary protein excretion was reduced by 90%. Some doubt exists among nephrologists about using cytotoxic drugs to treat patients other than those at high risk of renal failure. In Europe, a controlled study (Ponticelli et al) and a few uncontrolled trials have supported the use of this agent.
eAJKD: What do you think contributed to the 9 patients who had partial remission with ACTH?
AB: It is possible that patients just partly responsive to ACTH may have more advanced glomerular damage than the completely responsive patients. The patients were actually treated with activated melanocortinreceptor (MCR) MCR 1, 3, 4 and 5. Steroids as monotherapy have no place in the treatment of MN. A combination of ACTH and a low dose immunosuppressant (CsA) may be beneficial for inducing complete remission of proteinuria in patients with MN. An observational study of ACTH treatment in combination with Cyclosporine (CsA), for treatment of membranous nephropathy was presented at ASN 2012. With ACTH treatment those patients decreased significantly in proteinuria to partial remission by ACTH therapy but with low dose of CsA in combination with ACTH the patient reached complete remission with no change in kidney function. After the addition of a low dose of CsA, 8 of 10 patients achieved complete remission and 2 had still partial remission. A combination of ACTH and a low dose immunosuppressant may be beneficial for inducing complete remission of proteinuria in patients with MN who are only partially responsive to ACTH monotherapy.
eAJKD: Where do you and your group go from here?
AB: The goal is to continue to introduce a safe ACTH treatment as mono- or combination therapy in nephrotic patients and evaluate the clinical efficiency. It is also of importance to study the action of ACTH on glomerular function and on white blood cells and seek a more specific treatment for nephrotic patients.
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