REVIEWS

Treatment of membranous
nephropathy: time for a paradigm shift
Piero Ruggenenti1,2, Fernando C. Fervenza3 and Giuseppe Remuzzi1,2,4
Abstract | In patients with membranous nephropathy, alkylating agents (cyclophosphamide or
chlorambucil) alone or in combination with steroids achieve remission of nephrotic syndrome
more effectively than conservative treatment or steroids alone, but can cause myelotoxicity,
infections, and cancer. Calcineurin inhibitors can improve proteinuria, but are nephrotoxic.
Most patients relapse after treatment withdrawal and can become treatment dependent, which
increases the risk of nephrotoxicity. The discovery of nephritogenic autoantibodies against
podocyte M‑type phospholipase A2 receptor (PLA2R) and thrombospondin type‑1 domain-
containing protein 7A (THSD7A) antigens provides a clear pathophysiological rationale for
interventions that specifically target B‑cell lineages to prevent antibody production and
subepithelial deposition. The anti‑CD20 monoclonal antibody rituximab is safe and achieves
remission of proteinuria in approximately two-thirds of patients with membranous nephropathy.
In those with PLA2R-related disease, remission can be predicted by anti-PLA2R antibody depletion
and relapse by antibody re‑emergence into the circulation. Thus, integrated evaluation of
serology and proteinuria could guide identification of affected patients and treatment with
individually tailored protocols. Nonspecific and toxic immunosuppressive regimens will fall out
of use. B-cell modulation by rituximab and second-generation anti‑CD20 antibodies (or plasma
cell-targeted therapy in anti‑CD20 resistant forms of disease) will lead to a novel therapeutic
paradigm for patients with membranous nephropathy.

1
IRCCS – Istituto di Ricerche
Farmacologiche Mario Negri,
Centro Anna Maria Astori,
Science and Technology Park
Kilometro Rosso,
Via Stezzano 87,
24126 Bergamo, Italy.
2
Unit of Nephrology and
Dialysis, Azienda Socio-
Sanitaria Territoriale Papa
Giovanni XXIII, Piazza OMS 1,
24128, Bergamo, Italy.
3
Division of Nephrology and
Hypertension, Mayo Clinic,
200 First Street SW,
Rochester, Minnesota, USA.
4
Department of Biomedical
and Clinical Sciences,
University of Milan, Via Festa
del Perdono 7, 20122 Milan
Italy.
Correspondence to G.R.
Giuseppe.remuzzi@
marionegri.it
doi:10.1038/nrneph.2017.92
Published online 3 Jul 2017
Membranous nephropathy is an immune-mediated dis-
ease that results from the deposition of IgG and com-
plement components onto the subepithelial layer of the
glomerular capillary wall. The disease affects ~5–10
patients per million population and is the leading cause
of nephrotic syndrome in adults1. Solid or haematological
malignancies, systemic autoimmune diseases, infections
or the chronic consumption of drugs such as gold salts,
NSAIDs and penicillamine seem to have a role in disease
pathogenesis in approximately one-third of cases, which
are usually classified as secondary forms of membranous
nephropathy. A majority of the remaining 70% of cases
are defined by the presence of specific nephritogenic
autoantibodies and are usually described as primary
membranous nephropathy. The term idiopathic mem-
branous nephropathy should probably be restricted to
cases in which autoantibodies cannot be identified. To
avoid confusion, here we refer to primary and idiopathic
forms simply as membranous nephropathy 2.
Patients with membranous nephropathy and non-­
nephrotic proteinuria (<3.5 g per 24 h) have a good
prognosis with supportive therapy. Supportive therapy
involves the use of medications that do not interfere with
disease-specific mechanisms but instead aims to correct
or ameliorate concomitant pathophysiological changes
that might contribute to disease progression or the onset
of complications such as proteinuria, which is the strong-
est predictor of disease outcome in membranous nephro­
pathy and most other chronic nephropathies3–5. Without
immunosuppression, approximately one-third of patients
with membranous nephropathy and nephrotic syndrome
(proteinuria >3.5 g per 24 h and/or hypoalbuminaemia)
will progress to end-stage renal disease (ESRD)6. By con-
trast, the clinical condition of some of the remaining two-
thirds of patients will remain stable over time, whereas
others will achieve spontaneous remission of proteinuria
with sustained stabilization of renal function7. The ina-
bility of nephrologists to discriminate between progres-
sive and non-progressive disease has therefore fuelled
lively debate about the optimal treatment of patients with
­membranous nephropathy and nephrotic syndrome8.
Following a brief discussion of the role of supportive
therapy and the risk:benefit profile of traditional, non-
specific immunosuppressive regimens, here we focus on

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Key points whenever feasible (although symptomatic hypo­

tension can be an insuperable barrier in normotensive
• Steroids and alkylating agents increase the rate of remission in patients with patients22,23) to improve glomerular barrier size selectiv-
membranous nephropathy but can cause diabetes mellitus, myelotoxicity, infections, ity, reduce proteinuria, and increase serum albumin ­levels
cancer, and other adverse events with consequent correction of hypercholesterolaemia
• Calcineurin inhibitors can reduce proteinuria in patients with membranous and other components of the nephrotic syndrome24,25.
nephropathy but are nephrotoxic, and these agents should be avoided in patients ACE inhibitors can also reduce serum triglyceride levels
with abnormal kidney function
by improving insulin sensitivity 24.
• The discovery of nephritogenic autoantibodies provided a clear rationale for The Remission Clinic programme, which employs
interventions specifically aimed at preventing formation of antigen–antibody
a multimodal intervention strategy that is titrated to
immunocomplexes with secondary complement activation, podocyte damage,
and proteinuria
urinary protein level and maximal RAS inhibition
(BOX 1), slowed the decline in glomerular filtration rate
• B cell-targeted therapy with rituximab is at least as effective as steroids and alkylating
agents in achieving remission in membranous nephropathy, and available evidence
and almost fully prevented progression to ESRD in
suggests that it is safer and better tolerated patients with nephrotic syndrome secondary to chronic
• In patients with anti-PLA2R-related membranous nephropathy and overt nephrotic
nephropathies, including membranous nephropathy 26–28.
syndrome, evaluation of serum autoantibody titre and albumin levels, as well as This finding is clinically relevant because, as mentioned
assessment of proteinuria could guide tailored therapy above, proteinuria is the strongest predictor of long-term
• Traditional immunosuppressive regimens will be replaced by specific, nontoxic agents renal outcome in patients with chronic kidney disease.
such as B cell-targeting monoclonal antibodies; modulation of B-cell immunity could Indeed, either complete or partial remission of protein-
lead to a novel therapeutic paradigm in membranous nephropathy uria protects from progression to ESRD, an effect that
correlates with duration of remission and is independent
of age, sex, and residual kidney function3. In this con-
novel and safer treatment approaches involving B cell-­ text, immunosuppressive therapy might be indicated
depleting monoclonal antibodies, such as rituximab for patients with membranous nephropathy who do not
or ofatumumab, which specifically target mechanisms achieve remission with supportive therapy alone or can-
involved in the production of autoantibodies that lead to not implement the Remission Clinic protocol because of
progressive structural damage and kidney dysfunction. symptomatic hypotension or hyperkalaemia25.
Finally, we discuss the potential role of rescue therapy
with agents that target plasma cells, which might prevent Traditional immunosuppressive therapy
antibody–antigen interactions and immune complex-­ Whether specific interventions (TABLE 1) improve disease
mediated complement activation. In the era of precision outcome compared with supportive therapy or placebo
medicine9, improved understanding of disease mech­ has not been established, as the trials that have been
anisms and the development of disease-specific medica- conducted were underpowered. In a systematic review
tions will hopefully pave the way to even safer and more that included 1,025 patients from 18 trials conducted up
effective individually tailored therapeutic options for to December 2003, glucocorticoids alone were found
patients with membranous nephropathy. not to affect proteinuria29. However, alkylating agents
(cyclophosphamide or chlorambucil) alone or in com-
Supportive therapy bination with steroids increased the rate of complete or
All patients with membranous nephropathy should partial remissions compared with supportive treatment
receive optimal supportive therapy to reduce pro- or steroids alone29. The treatment benefit was confined
teinuria 10. Treatments include renin–angiotensin to patients with serum creatinine level <1.1 mg/dl
system (RAS) inhibitors such as angiotensin-converting-­ (<97 μmol/l), that is, those patients who seldom progress
enzyme (ACE) inhibitors and angiotensin-receptor to ESRD, even without immunosuppression30. Moreover,
blockers (ARBs)5, which reduce protein ultrafiltration serious adverse events (SAEs) were much more frequent
by ameliorating glomerular hypertension and improving among patients receiving steroids or alkylating agents
glomerular barrier size selectivity11,12. Proteinuria usually than among other patients29. Cyclophosphamide is safer
decreases within 2 months of treatment 13. However, in than chlorambucil but results in more treatment with-
patients with severe proteinuria (that is, those who are drawals and hospitalizations than conservative ther-
at highest risk of disease progression), the decrease is apy 31,32. No treatment benefits, only adverse effects, were
seldom >30% from pretreatment values13,14. RAS inhibi- observed with ciclosporin31. In a large, randomized con-
tors therefore seem to be less nephroprotective in mem- trolled trial (RCT) conducted in the UK, steroids plus
branous nephropathy than in other proteinuric chronic chlorambucil were found to slow the loss of renal func-
nephropathies15–18. Combination therapy with aldoster- tion compared with supportive therapy alone in patients
one antagonists19 or NSAIDs20 does not add to the anti- with membranous nephropathy 33. However, the 3‑year
proteinuric effects of RAS inhibitors, and could increase follow‑up period was too short to evaluate whether
serum potassium levels. Combination therapy with ACE treatment also prevented ESRD. Moreover, prednisolone
inhibitors and ARBs is more effective at reducing pro- and chlorambucil combination therapy was associated
teinuria than ACE inhibitor or ARB monotherapy in with a nearly twofold higher incidence of SAEs com-
patients with chronic nephropathy not related to dia- pared with supportive therapy (2.8 events per patient
betes mellitus, including membranous nephropathy 21. versus 1.5 events per patient). Overall, 36 of the 56 events
Dual RAS blockade should therefore be implemented observed with specific treatment were thought possibly

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or likely to be treatment-related. Events included two
malignancies, 28 cases of bone marrow toxicity, and
eight of impaired glucose tolerance. This event rate
exceeded the rates reported in previous RCTs of alkylat-
ing agents in membranous nephropathy 34,35. In 1996, the
International Conference on Harmonization of Technical
Requirements for Registration of Pharmaceuticals for
Human Use defined the Guidelines for Good Clinical
Practice, including monitoring of SAEs36. Before this
time, the under-reporting of such events could have
contributed to the general underestimation of the risks
associated with heavy immunosuppression. Similarly,
in countries that formally adopted the guidelines in the
past few years37, more-recent (post‑1996) studies are
also likely to be affected by underestimation of adverse
events38. Even in well conducted trials33, adverse events
such as lymphomas and other malignant diseases, which
can occur as late as 10–20 years after treatment, are likely
to be missed39. The risk of malignancies and other seri-
ous complications — including post-transplant lympho­
proliferative disorders, opportunistic infections, and
osteomuscular disease — increases when patients who
progress to ESRD receive a kidney transplant and receive
immunosuppressive therapy to prevent graft rejection.
Thus, the risk:benefit profile of combination ther-
apy with steroids and chlorambucil is poor, particularly
in patients at increased risk of treatment-related SAEs
because of kidney function impairment or rapid renal
function loss (the majority of patients enrolled in the UK
trial33). Even in patients with a normal and stable glo-
merular filtration rate, the adverse effects of chlorambu-
cil have led the nephrology community to recommend
that chlorambucil should not be used in the treatment
of membranous nephropathy 10. An adequately powered
RCT to assess the long-term benefits and risks of com-
bination therapy with steroids and cyclophosphamide
would require hundreds of patients to be followed‑up
for 10–20 years40, but such a trial would not be justified
given the availability of novel and safer treatments41.
Indeed, since the late 1990s42, research has been tar-
geted towards the identification of novel treatments
that achieve the same benefits as existing therapies
but with substantially fewer adverse effects. Improved
understanding of disease mechanisms43 has provided a
strong rationale for more specific approaches that will
potentially address important unmet needs in patients
with membranous nephropathy, particularly for those
with persistent nephrotic syndrome and worsening
­kidney function44.
The Kidney Disease: Improving Global Outcomes
(KDIGO) guidelines published in 2012 confirmed that
treatment with alkylating agents should be restricted
to patients with persistent nephrotic syndrome10. The
rationale is that, in these patients, the risks of treat-
ment would be counterbalanced by the reduced risk
of ESRD. In fact, a long-term, single centre, cohort
study showed that a restrictive approach prevented
51% of 254 patients with membranous nephropathy
from receiving unneces­sary treatment 45. In this series,
steroids and cyclophosphamide were administered for
6–12 months only to patients with worsening kidney
Box 1 | The Remission Clinic protocol*
• Low sodium diet with or without diuretics and protein
intake 0.8–1.0 mg/kg per day‡
• Dual renin–angiotensin system blockade with
maximum tolerated doses of ACEIs and ARBs
-- Start and up‑titrate an ACEI (or ARB)‡
-- Start and up‑titrate an ARB (or ACEI)‡
• Start and up‑titrate other antihypertensive agents to
achieve the maximum tolerated reduction in blood
pressure (consider dihydropyridine calcium-channel
blockers as a last resort)
• Add a lipid-lowering agent
*A response-driven, individually tailored approach to target
proteinuria <0.3 g per 24 h. ‡Before moving to the next step,
check serum potassium levels and optimize metabolic acidosis
and hyperglycaemia control to minimize the risk of
hyperkalaemia. ACEI, angiotensin-converting-enzyme
inhibitor; ARB, angiotensin-receptor blocker.
function or severe, disabling symptoms of nephrotic
syndrome. Over 10 years, the rate of remissions was
similar in patients given immunosuppressive therapy
and in those who received conservative therapy alone,
despite membranous nephropathy being less severe at
baseline in the conservative therapy group. However,
severe adverse events were remarkably more frequent
in patients who underwent immunosuppression. In
particular, 15% of the 91 patients given cyclophospha-
mide developed a malignancy compared with only 3%
of the 130 who received conservative therapy. This dif-
ference was statistically significant, and in eight patients
the malignancy was fatal. Moreover, patients receiving
cyclophosphamide had higher rates of hospitalization,
infection, bone marrow and liver toxicity, and cardio-
vascular and thrombotic events than patients who were
treated conservatively 45. Therefore, even when immu-
nosuppression is restricted to patients at increased risk
of disease progression, SAEs remain an important issue.
In this study 45, average patient exposure to cyclophos-
phamide exceeded the cumulative exposure of the tra-
ditional cyclical cyclophosphamide regimen10. However,
the risk of SAEs remained when analyses were restricted
to patients who received a cumulative dose of <20 g
cyclophosphamide or when the observation period was
restricted to the first 3 months or 6 months of immuno-
suppressive therapy 41. In this context, cyclophosphamide
has been associated with an increased risk of malignancy
even at cumulative doses of 12 g (REF. 46). Historical treat-
ment approaches in membranous nephropathy have
been comprehensively reviewed elsewhere47,48.
Towards disease-specific therapy
Membranous nephropathy was first described as a spe-
cific disease entity in 1957 by David Jones49. In 1959,
the finding that rats injected with an extract of proxi-
mal tubular cells induced the deposition of subepithelial
immune complexes that were similar to those observed
in humans with membranous nephropathy, strongly
suggested the possibility of an immune-mediated
patho­genesis of the disease50. These immunocomplexes,

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Table 1 | Treatment of membranous nephropathy: conventional immunosuppressive protocols*

Regimen Drug Dose Schedule
Alkylating agents plus steroid combination therapy ‡

Chlorambucil Chlorambucil 0.2 mg/kg per day Months 2, 4, and 6

cyclical therapy
Prednisolone 0.5 mg/kg per day Months 1, 3, and 5
Methylprednisolone 1 g IV Three consecutive days at start
of months 1, 3, and 5
Cyclophosphamide Cyclophosphamide 2.5 mg/kg per day§ Months 2, 4, and 6
cyclical therapy
Prednisolone 0.5 mg/kg per day Months 1, 3, and 5
Methylprednisolone 1 g IV Three consecutive days at start
of months 1, 3, and 5
Cyclophosphamide Cyclophosphamide 1.5 mg/kg per day Months 1–6||
daily therapy
Prednisolone 0.5 mg/kg every second day Months 1–5, then taper dose
to stop in 6–8 weeks
Methylprednisolone 1 g IV Three consecutive days at start
of months 1, 3, and 5
Calcineurin inhibition therapy¶
Ciclosporin regimen Ciclosporin Initial dose 3.5 mg/kg per day, trough Months 1–6, then taper dose
level 125–225 μg/l by 25% each month; continue
treatment at 50% of dose until
12 months, then taper to lowest
possible maintenance dose#
Prednisolone** 0.15 mg/kg per day Months 1–6, then taper dose
(maximum of 15 mg)
Tacrolimus regimen Tacrolimus Initial dose 0.05 mg/kg per day, achieve Months 1–12, then taper to
trough level 3–5 ng/l; if remission is not lowest possible maintenance
achieved after 2 months, increase to dose||
5–8 ng/l
Prednisolone** 0.15 mg/kg per day Months 1–6, then taper dose
(maximum of 15 mg)
*Some immunosuppressive regimens require prophylactic measures to prevent adverse effects. ‡ Effectiveness documented in
controlled clinical trials, but with major and potentially fatal adverse effects; not recommended. §The Kidney Disease: Improving
Global Outcomes guidelines recommend 2 mg/kg per day10 .||Cyclophosphamide used for 12 months in REF. 45; treatment duration
is now limited to 6 months. ¶Unproven effectiveness with adverse effects, including nephrotoxicity; not recommended. #Incidence
of relapse is high; treatment must be continued in most patients. **Whether prednisolone coadministration is needed is unknown.
IV, intravenous.

however, contained IgG antibodies target­ing mega-
lin, a protein expressed on both rat tubuli and podo-
cytes51, but not on human podocytes. A target antigen
in humans was first identified in 2002 in the baby of
a woman with a neutral endopeptidase (NEP) defi-
ciency 52. The finding that anti-NEP alloantibodies pro-
duced by the mother crossed the placenta and bound to
NEP expressed on fetal podocytes52 confirmed the role
of autoantibodies in the pathogenesis of membranous
nephropathy in humans.
In 2009, circulating autoantibodies against the
M-type phospholipase A2 receptor (PLA2R), primarily
of the IgG4 subclass, were detected in ~70% of patients
with membranous nephropathy 43. Antibodies were dis-
ease specific as they could not be found in patients with
other proteinuric nephropathies43, but were associated
with membranous nephropathy in several cohorts of
patients of different ethnicities53,54. The pathogenic role
of the PLA2R antigen was confirmed by the significant
association found between single nucleotide poly­morph­
isms in the PLA2R gene and the development of the
disease55.
Circulating autoantibodies against another human
podocyte antigen — the thrombospondin type  1
domain containing 7A protein (THSD7A) — have been
subsequently observed in 5–10% of patients with mem-
branous nephropathy who do not have circulating anti-
PLA2R autoantibodies56. The finding that most patients
with membranous nephropathy have an autoimmune
response against either PLA2R or THSD7A, but very
rarely against both57, suggests that both antigens can be
the primary target of specific autoimmunity and con-
firms that PLA2R-associated membranous nephropathy
and THSD7A‑associated membranous nephropathy are
separate disease entities2.
Several studies have since documented that anti-
PLA2R antibody titre correlates with disease activity
and patient outcomes53,58–65. Low autoantibody levels at
diagnosis predict spontaneous remission66,67, whereas
high baseline anti-PLA2R antibody levels correlate with
a reduced probability of spontaneous remission66, are
associated with progression to nephrotic syndrome
in patients with initial non-nephrotic proteinuria64,
and predict a high risk of relapse and progressive loss

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Antibody-secreting CysR domain were younger, had less severe proteinuria, a

cell (including
plasmablasts, plasma
Immature Mature Activated
cells and long-lived
Pro-B cell Pre-B cell B cell B cell B cell
memory cells)
CD20 CD38
BAFF-R,
BCMA BLyS Anti-PLA2R
or TACI
Anti-THSD7A
Targets for anti-BLyS Targets for anti-CD38
antibodies (e.g. belimumab) antibodies
(e.g. daratumumab
Targets for anti-CD20 monoclonal antibodies or isatuximab) and
(e.g. rituximab or ofatumumab) protease inhibitors
(e.g. bortezomib)
Figure 1 | Targets for monoclonal antibodies in B-cell lineages. B cells emerge from
Nature
bone marrow stem cells as pro‑B cells and mature into pre‑B cells, ReviewsB cells,
immature | Nephrology
mature
B cells, and activated B cells. Eventually, they develop into antibody-secreting cells,
including plasmablasts, plasma cells, and long-lived memory plasma cells that secrete IgA,
IgE, IgG, and IgM antibodies. Autoreactive B‑cell clones can produce anti-M-type
phospholipase A2 receptor (PLA2R) and anti‑thrombospondin type 1 domain containing 7A
protein (THSD7A) antibodies and conceivably, autoantibodies against unknown antigens
expressed on podocytes. As B cells mature, they develop various markers on the cell surface
that can become targets for specific monoclonal antibodies. Anti‑CD20 monoclonal
antibodies, such as rituximab and ofatumumab, bind and kill CD20‑expressing B cells
(pre‑B cells, and immature, mature, and activated B cells), but not plasmablasts, mature
plasma cells or memory plasma cells as they do not express this antigen. Plasma cells
express CD38 and might, therefore, be a target for anti‑CD38 antibodies such as
daratumumab and isatuximab. Immature, mature, and activated B cells express receptors
for the B lymphocyte stimulator (BLyS, also known as BAFF) such as B cell activating factor
receptor (BAFF‑R), B cell maturation antigen (BCMA), and the transmembrane activator
and calcium-modulating cyclophilin ligand interactor (TACI). The anti-BLyS monoclonal
antibody belimumab might, therefore, prevent B-cell differentiation into plasma cells by
blocking the interaction between this lymphocyte stimulator and its receptors. Proteasome
inhibitors, such as bortezomib, can prevent antibody production by inducing plasma cell
apoptosis, whereas anti‑CD38 monoclonal antibodies, such as daratumumab and
isatuximab, can directly induce plasma cell cytolysis.
of kidney function63,64,68. Moreover, decreasing anti-
PLA2R antibody levels strongly predict remission of
protein­uria53,62,69 and response to various traditional
and novel CD20‑targeted immunosuppressive treat-
ments62,65. Preliminary data suggest the same will be true
for anti‑THSD7A antibody levels in predicting disease
activity and response to therapy 56,70.
Disease severity and response to treatment of patients
with membranous nephropathy is influenced not only by
the overall titre of circulating anti-PLA2R autoantibodies
but also by the nature of these antibodies. PLA2R1 is a
membrane receptor that has a large extracellular region
which includes a cystein-rich domain (CysR) and eight
different C‑type lectin domains (CTLD1–8)71. The CysR
domain is probably the dominant epitope of the PLA2R1
antigen72; However, site-directed mutagenesis experi-
ments have identified CTLD1 and CTLD7 as additional
and distinct PLA2R1 epitopes that could act as potential
targets of anti-PLA2R autoreactivity73. The finding that
patients with isolated anti-PLA2R reactivity against the
higher rate of spontaneous remissions, and a lower risk of
progression to ESRD than patients who also showed anti-
body reactivity against CTLD1 and/or CTLD7 domains
indicated that the epitope profile could change over time
and that epitope spreading towards CTLD1 and CTLD7
might negatively affect disease outcome73. These findings
led to the hypothesis that antiPLA2R reactivity restricted
to the CysR domain might be associated with initial and
milder stages of the disease, whereas additional immune
challenges might induce antigen intramolecular spread-
ing towards the C‑terminus. Thus, as observed in other
human immune diseases74 and Heymann nephritis —
an experimental counterpart of human membranous
nephropathy 75 — the emergence of new epitopes, such
as CTLD1 and CTLD7 in patients with membranous
nephropathy might be associated with disease worsen-
ing and decreased responsiveness to therapy 73. Thus,
qualitative evaluation of antiPLA2R reactivity through
the development of epitope-specific anti-PLA2R assays,
in combination with the measurement of overall anti-
PLA2R titre, might improve monitoring of disease activity
and response to therapy. Whether similar considerations
might apply also to the THSD7A antigen is unknown.
In a long-term cohort study of 132 patients with
membranous nephropathy and chronic nephrotic
syndrome, a lower antibody titre strongly predicted a
higher rate of complete or partial remission and a faster
progression to the event following treatment with the
anti‑CD20 monoclonal antibody rituximab65. Moreover,
the reduction or depletion of anti-PLA2R autoantibodies
at 6 months strongly predicted disease remission during
follow‑up, and a 50% decrease in antibody titre preceded
an equivalent decrease in proteinuria by 10 months65.
Sensitivity analyses confirmed that short-term changes
in antibody titre strongly predicted long-term disease
outcome (complete remission was considered a single
end point, and remission of nephrotic syndrome com-
bined with an increase in serum albumin to normal
levels was a more restrictive end point in patients with
hypoalbuminaemia at baseline)65. Response to treatment
was similar in patients with or without detectable anti-
bodies or for whom antibody data were not available65.
These findings strongly suggest that in a substantial pro-
portion of patients who are anti-PLA2R negative, mem-
branous nephropathy is sustained by other, unknown
autoantibodies, and that the production of these anti-
bodies is affected by rituximab therapy to a similar
extent as is anti-PLA2R.
After almost 40 years of empirical treatment, the dis-
covery of anti-PLA2R and anti‑THSD7A autoanti­bodies
provided the first clear pathophysiological rationale for
interventions specifically aimed at preventing anti-
body production (FIG. 1) and subepithelial deposition of
antibody–­antigen immunocomplexes (FIG. 2). Such treat-
ments could potentially prevent complement activation
and podocyte damage, eliminate nephrotic syndrome,
and even resolve the glomerular pathology of mem-
branous nephropathy 76,77. In this context, combined
assessment of circulating anti-PLA2R or anti‑THSD7A
autoantibodies and proteinuria, and serum albumin level

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a b
Podocyte
Immuno-
complexes

8
7 8
6 7
5
4 5
6
8 Complement
activation
3 4 7
2 3 6
1 2 5
1 4
3
2
1

Podocyte
damage

Proteinuria

Anti-PLA2R against PLA2R CysR domain PLA2R CysR domain PLA2R FNII domain

Anti-PLA2R against PLA2R CTLD1 domain PLA2R CTLD domains (1–8)

Anti-PLA2R against PLA2R CTLD7 domain PLA2R transmembrane and intracellular domains

Figure 2 | Prevention of antigen–antibody immunocomplex deposition on the glomerular basement membrane.

Nature Reviews | Nephrology
a | A glomerular capillary and its basement membrane surrounded by podocytes. Anti-M-type phospholipase A2
receptor (PLA2R) antibodies are shown in the capillary lumen. b | Binding of circulating anti PLA2R autoantibodies to their
specific cystein-rich domain (CysR), C-type lectin domain (CTLD)1 or CTLD7 epitopes expressed by the PLA2R receptor
on the podocyte cell surface leads to the deposition of antigen–antibody subepithelial immunocomplexes that activate
the complement system with secondary podocyte damage and proteinuria. In theory, antibody–antigen binding and the
deposition of subepithelial immunocomplexes could be prevented by epitope-specific ligands that bind circulating
antiPLA2R antibodies and prevent their binding to epitopes of the PLA2R antigen.

in patients with hypoalbuminaemia, could be instru-
mental in monitoring disease activity and guiding per-
sonalized therapy with conventional immuno­suppressive
protocols or specific B cell-targeting monoclonal anti-
bodies78. Indeed, antibody levels provide a prompt and
reliable indication of immunological status and an inte-
grated evaluation of serology and proteinuria might
accelerate therapeutic decision-making and address
diagnostic uncertainties when proteinuria and antibody
levels are discordant. Specifically, persistent proteinuria
in the face of low antibody levels might reflect chronic
damage, whereas high antibody levels in the absence of
clinical symptoms could signal an impending relapse.
This integrated approach to membranous nephropathy
could increase diagnostic and prognostic accuracy, limit
unnecessary exposure to immunosuppressive therapy,
optimize efficacy of treatment, and minimize the risk or
severity of recurrent disease in allotransplants78. These
theories can now be addressed in prospective studies
designed to test whether treatment titration to auto­
antibody titre will increase the probability of achieving
remission from nephrotic syndrome and prevent relapse
while decreasing the risk of treatment-related adverse
effects. In antibody-negative patients, proteinuria and
serum albumin levels remain the most sensitive markers
of disease severity and outcome.
Monoclonal antibodies: rituximab
Prior to the finding that anti-PLA2R autoantibodies
have a central role in the pathogenesis of human mem-
branous nephropathy 43, data from animal studies had
consistently shown that antibodies produced by auto­
reactive B-cell clones initiate events resulting in injury to
the glomerular barrier and the development of protein­
uria79. Consistent with these observations, cyclophos-
phamide has a direct inhibitory effect on B cell antibody
production in membranous nephropathy, adding to
the non­specific antimitotic and immunosuppressive
properties that mediate many of the adverse effects of
this drug 80. The availability of a monoclonal antibody
against the B-cell surface antigen CD20 (REF. 81) has ena-
bled investigation into whether targeted B‑cell depletion
with inhibition of nephritogenic autoantibody produc-
tion improves the outcome of patients with membran­
ous nephropathy while avoiding the adverse effects of
­steroids and immunosuppressants (TABLE 2).
Against this background, the anti‑CD20 mono­clonal
antibody rituximab was tested in eight patients with
membranous nephropathy and long-term proteinuria42.
Over 20 weeks of follow‑up, proteinuria decreased by 62%
and serum albumin level increased by 31% compared to
baseline levels. In two patients proteinuria decreased
to <1 g per 24 h and in three patients to <3.5 g per 24 h,
and no SAEs occurred42. The reduction in proteinuria
was sustained over 1 year and was associated with stable
kidney function and a reduction in body weight, blood
pressure, and serum cholesterol level82. These seminal
observations were confirmed by subsequent studies22,23,83.
Among 35 patients with membranous nephropathy (half
of whom had not been responsive to immunosuppres-
sant therapy), rituximab administered at a dose of two
1 g infusions 2 weeks apart, or four once-weekly infusions

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Table 2 | Treatment for membranous nephropathy: B cell and plasma cell-targeted protocols
Target Drug Dose Schedule
Anti‑CD20 monoclonal Rituximab • 375 mg/m intravenously
2
• Every week for 4 weeks
antibodies* • 375 mg/m2 intravenously • B cell-driven treatment‡
• 1,000 mg intravenously • Days 1 and 15
Ofatumumab 300 mg intravenously B cell-driven treatment‡
Anti-BLyS monoclonal Belimumab 10 mg/kg intravenously • Every 4 weeks (if urinary
antibodies§ protein:creatinine ratio <1,000
mg/mmol)
• Every 2 weeks (if urinary
protein:creatinine ratio >1,000
mg/mmol)
Plasma cell-targeted protocols Bortezomib 1.3 mg/m2 subcutaneously Four doses over 2 weeks
(proteasome inhibitors||)
*Safe and well tolerated. Effectiveness of rituximab proven in randomized trials and observational studies. Preliminary observational
evidence of efficacy for ofatumumab in rituximab-resistant forms of membranous nephropathy. ‡A second 375 mg/m2 dose of
rituximab or a second dose of 300 mg of ofatumumab are administered 1 week after the first infusion if >5 circulating B cells per mm3
remain. §Preliminary evidence of efficacy from a small, randomized pilot study; no long-term data available. ||Preliminary observational
evidence of efficacy in rituximab-resistant forms of membranous nephropathy; serious adverse effects. BLyS, B lymphocyte stimulator.

of 375 mg/m2, achieved complete or partial remission of
proteinuria in 50% and 80% of patients at 1 year and at
2 years, respectively 22,23. The reduction in proteinuria was
similar with the two dosing regimens, and was gradual
and sustained over time. The recovery of B-cell counts
once treatment was completed, however, was faster in
patients with proteinuric membranous nephropathy than
in patients without proteinuria treated with rituximab,
such as those with rheumatoid arthritis, non-Hodgkin
lymphoma, or antineutrophil cytoplasmic antibody
(ANCA)- associated vasculitis22,23,84,85. This finding sug-
gests that rituximab is lost in the urine of patients with
severe proteinuria. However, rituximab levels did not
correlate with treatment response22,23.
In a single-centre cohort study published in 2012,
B‑cell depletion led to complete or partial remission
of nephrotic syndrome in 65% of 100 patients, and an
additional 20 patients experienced a >50% reduction
in proteinuria86. The median duration of proteinuria
before rituximab administration was >2 years (~6 years
in those previously exposed to other immunosuppressive
regimens), and all patients had been taking ACE inhibi-
tors or ARBs for at least 6 months. Therefore, remission
of nephrotic syndrome in these patients was unlikely
to have been spontaneous. Again, the antiproteinuric
effect was progressive over time and, at the 4‑year follow
up, all patients had achieved complete or partial remis-
sion86. Data from other studies indicating that depletion
of anti-PLA2R antibodies precedes remission of the
nephrotic syndrome59,65 and that their re-emergence
precedes disease recurrence65, provides convincing evi-
dence of a causal relationship between anti-PLA2R anti-
body production and disease activity. The finding that
the reduction in proteinuria up to the point of complete
remission follows B‑cell depletion by several months is
consistent with evidence that the resolution of in situ
immune deposits is a slow and progressive phenom­enon
that occurs several months after transplantation of kid-
neys from rats with experimental membranous nephro­
pathy (Heymann nephritis) into syngeneic rats without
the disease87.
Irrespective of the mechanisms of drug action, a
matched cohort study showed that rituximab safely and
persistently reduced proteinuria in untreated patients and
in those who did not respond to immunosuppressive ther-
apy or relapsed after transient remission88. Among 100
patients with membranous nephropathy and nephrotic
syndrome, the rates of remission were similar with ritux-
imab as a first-line therapy and as a ‘rescue’ therapy 86.
Rituximab also enabled successful withdrawal of tacroli-
mus or ciclosporin in 13 calcineurin inhibitor-dependent
patients89. Three patients experienced relapse of nephrotic
syndrome over a period of 35 months but fully recovered
following a second course of rituximab89.
Together, these data indicate that selective B‑cell
depletion by rituximab is at least as effective as other
conventional immunosuppressive regimens in promot-
ing disease remission in patients with membranous
nephropathy and severe nephrotic syndrome, even
after other treatments have failed. Importantly, clinical
benefits are associated with regression of the histologi-
cal lesions characteristic of membranous nephropathy,
along with decreased glomerular IgG4 and C3 staining,
reabsorption of electron-dense subepithelial deposits, an
increased number of podocyte slit diaphragms, and an
increased percentage of electron-dense slit diaphragms76.
These findings, combined with data showing that a
decrease in albumin fractional clearance is correlated
with an increase in electron-dense diaphragms, pro-
vides evidence that rituximab interferes with the mech-
anisms of membranous nephropathy 76. Regression of
histological changes was also observed in isolated cases
of membranous nephropathy described decades before
rituximab became available for clinical use90–92; how-
ever, whether they reflect treatment-induced or spon-
taneous remission of the disease is difficult to establish.
By contrast, although ciclosporin was shown to effec-
tively reduce proteinuria in patients with membranous
nephropathy, repeat renal biopsy demonstrated that
electron-dense immune deposits associated with the glo-
merular capillary wall were more numerous and larger
after ciclosporin therapy than before93.

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An important, but frequently neglected benefit of
rituximab is its major impact on patient quality of life94.
Patients receiving rituximab benefit from the improve-
ment in symptoms associated with remission of protein-
uria and discontinuation of other immunosuppressive
medications. By contrast, in patients treated with ster-
oids, alkylating agents or calcineurin inhibitors, quality
of life is detrimentally affected by the toxicities of these
medications, even when remission is achieved94.
Comparative safety of rituximab
Rituximab is generally well tolerated. In five randomized
controlled trials95–99, the average incidence of severe
infections in patients treated with rituximab (10%)
was comparable to that observed in patients receiving
placebo (12%). A study of case descriptions of patients
treated with rituximab from 1997 to 2008 identified 57
patients with progressive multifocal leukoencephalopa-
thy (PML)100. 52 of these patients had lymphoproliferative
disorders and five had autoimmune diseases. All of the
patients had previously been exposed to corticosteroids
and several chemotherapeutic agents, including cyclo-
phosphamide in 74% and chlorambucil in 21% of cases,
in various combinations. No patient received rituximab
as the only immunosuppressive medication. Moreover,
it is unknown how many patients —conceivably sev-
eral thousands — had been exposed to rituximab at the
same centres over the observation period without devel-
oping PML. On the basis of this observational study, it
is impossible to establish a causal relationship between
exposure to rituximab and development of PML100. On
the other hand, >30 cases of PML have been described
in patients with vasculitis associated with systemic lupus
erythematosus (SLE) or ANCA who were treated with
cyclophosphamide-based regimens101,102. In the case of a
child with steroid-dependent idiopathic nephrotic syn-
drome, exposure to other immunosuppressant drugs is
likely to have been involved in the development of fulmi-
nant enterovirus myocarditis requiring heart transplan-
tation 13 months after rituximab therapy 103. In fact, the
finding that replication of John Cunningham virus and
BK virus is not affected by rituximab therapy in children
with recurrent idiopathic nephrotic syndrome104 indi-
cates that complications related to viral reactivations
should not be more frequent with rituximab than with
conventional immunosuppressants. In an RCT of chil-
dren with frequently relapsing nephrotic syndrome, no
significant increase in the incidence of severe adverse
events was found with rituximab compared with pla-
cebo105. The incidence of infections was also comparable
between the two groups105. Moreover, the risk of infec-
tions and other complications is reduced when rituxi-
mab is used to aid ­withdrawal from steroids and other
immunosuppressants106.
In the context of membranous nephropathy, the
only adverse effects that can be ascribed with certainty
to rituximab are infusion-related events such as hypo-
tension, cutaneous rash, and bronchial wheezing 86.
These effects are not serious and resolve with tempo-
rary interruption of the infusion or, in exceptional cir-
cumstances, with hydrocortisone86. Premedication with
10 mg of chlorphenamine and 500 mg of hydrocortisone
minimizes the risk of these events. SAEs occurring after
exposure to rituximab are rare. In 100 patients treated
with rituximab77, the percentage who experienced an
SAE was lower than in the supportive therapy group of a
different trial33 (11% versus 42% over 29 and 36 months,
respectively). Moreover, the finding that SAEs clustered
in the subgroup of patients who did not achieve remis-
sion strongly suggests that these events were related to
the underlying disease rather than to treatment. The
rate of infections and cardiovascular events was actually
reduced in patients who achieved remission86.
The risk of SAEs such as malignancies that occur
as late as 10–20 years after treatment 39 and, therefore,
are not captured during the observation period, can-
not be excluded from trials of steroids and alkylating
agents32,35,38. However, data from patients receiving life-
long rituximab therapy for chronic lymphomas, or those
exposed to high cumulative doses for the treatment of
autoimmune diseases or lymphoproliferative disorders
over a >10‑year period, show that rituximab is safer than
other immunosuppressants107–109. In a large cohort of
patients with rheumatoid arthritis who were followed for
11 years, rituximab was not associated with an increased
risk of cancer 110. In another study, three malignancies
observed over a median of 29 months in 100 consecu-
tive patients with membranous nephropathy treated with
rituximab86 is likely to reflect the age-adjusted incidence
of cancer in the general population111. Of note, the patient
who eventually died of lung cancer had been previously
treated with steroids and alkylating agents. By contrast,
combined therapy with steroids and cyclophosphamide
in membranous nephropathy confers a threefold increase
in the risk of cancer compared with that of the general
population, which translates to an annual increase in
risk of 0.3–1.0%46. This finding is particularly relevant
for patients with membranous nephropathy who relapse
after treatment with cyclophosphamide, because sub-
sequent treatment will result in a cumulative dose of
­cyclophosphamide well above the safety threshold.
Within the limitations of comparisons across studies,
rituximab seems to be at least as effective as conventional
treatments for membranous nephropathy, but is safer.
Severe complications, such as PML, pneumocystis pneu-
monia, and pulmonary fibrosis that have been ascribed
to rituximab112 were observed in patients with lympho­
proliferative113 or autoimmune diseases114, or those who
had undergone bone marrow transplantation115, all of
whom had been exposed to other immunosuppressant
drugs. No such events have been reported in patients
receiving rituximab monotherapy, including those with
membranous nephropathy. Anecdotal evidence sug-
gests that, by allowing withdrawal of steroid and other
immuno­suppressants, rituximab may even favour remis-
sion of some of the above complications106, including
PML (P. Ruggenenti and G. Remuzzi; unpublished work).
Optimal dosing of rituximab
Rituximab treatment protocols for patients with mem-
branous nephropathy vary widely. The most frequently
used protocol involves a dose of 375 mg/m2 once a

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week for 4 weeks, but eight-dose ‘prolonged protocols’,
or ‘extended protocols’ with monthly infusions for 2 or
3 months following the standard four-dose regimen
have also been used116. However, CD20+ cells were found
to be absent from the circulation after a single dose of
rituximab in patients with membranous nephropathy
or SLE117,118. This finding questions the need for addi-
tional doses of rituximab, which could increase the risk
of adverse effects or sensitization and treatment costs,
without conferring additional benefits.
To address this question, a prospective 1:2
matched-cohort study compared the risk:benefit profile
of a B cell-driven rituximab treatment with the standard
four 375 mg/m2 dose rituximab protocol in 36 patients
with membranous nephropathy and nephrotic syndrome
refractory to conventional therapy 119. Patients allocated
to the B cell-driven protocol received a second infusion
of rituximab only if they had more than five B cells per
mm3 of peripheral blood after the first 375 mg/m2 dose,
which occurred in only one of the 12 patients in this
group119. The two treatments promptly and persistently
depleted circulating B cells in all patients and achieved
a similar time-dependent reduction in proteinuria.
However, adverse events and hospitalizations were less
frequent with the B cell-driven approach, which was also
fourfold less expensive119. Because of the remarkable
reduction in treatment costs (~€10,000 or ~US$13,000
per patient 119), the B cell-driven protocol should facil-
itate access to rituximab even in resource-limited set-
tings. Indeed, one 375 mg/m2 dose of rituximab in an
average 70 kg patient costs €3,206 ($4,275)120. The alter-
native treatment with intravenous and oral steroids plus
oral cyclophosphamide for 6 months at currently rec-
ommended doses costs approximately €450 ($600)121.
However, this figure does not include the cost of fre-
quent clinic visits to monitor blood cell counts and hos-
pitalizations because of treatment-related adverse events.
Considering that a 1‑day hospitalization in a noninten-
sive care unit, including a nephrology and dialysis unit,
costs €300–500 ($400–666)122, just one admission would
largely offset the costs saved with steroids plus alkylating
agents compared to the cost of rituximab therapy.
The current recommendation for patients with
membranous nephropathy is to use calcineurin
inhibitors for at least 12 months before considering
discontinuation10. In the USA, the average cost of a
calcineurin inhibitor at doses used for membranous
nephropathy is ~$700 per month123. To this expense
must be added the cost of monitoring drug levels and
of blood pressure-lowering medications needed to con-
trol treatment-induced hypertension. In the long-term,
treatment costs will increase as >50% of these patients
relapse within 12 months and 18 months after with-
drawal of ciclosporin and tacrolimus, respectively 124,125.
These relapses require further courses of calcineurin
inhibitors and multiple relapses are associated with a
doubling of serum creatinine level and progression to
ESRD48,126. Thus, additional costs will be incurred with
the need for repeated courses of calcineurin inhibitors
and to manage complications related to the chronic
nephrotoxicity of these agents.
Controlled studies of rituximab
The GEMRITUX trial. In the prospective, randomized,
controlled GEMRITUX clinical trial25, the effects of two
375 mg/m2 doses of rituximab were compared to non­
immunosuppressive antiproteinuric treatment (NIAT)
on the rate of complete or partial remissions at 6 months
(primary end point) in 75 patients with membranous
nephropathy and residual proteinuria (>3.5 g per 24 h)
despite maximal tolerated doses of ACE inhibitors or
ARBs, statins, and diuretics. The treatment effect was
evaluated after this short period of follow up so that
patients with persistent nephrotic syndrome could be
offered rescue treatment with other immunosuppressive
medications (particularly those in the control group who
received supportive NIAT only). At 6 months, numerically
more patients in the rituximab group than in the control
group reached the primary end point (13 versus eight), but
this difference was not significant25. By 17 months, how-
ever, the rate of complete or partial remission in rituxi-
mab group was almost twice that of controls (64.9% versus
34.2%), and the difference in remission rate was significant
(P = 0.03). Seven patients treated with rituximab achieved
complete remission compared to just one control25. This
finding was not surprising, because the antiproteinuric
effect of rituximab can take at least 12 months to fully
manifest86, an effect that is largely preceded by depletion
of circulating anti-PLA2R antibodies and an increase in
serum albumin concentration65. The time lag between the
start of immunosuppression and reduction in protein­
uria has been demonstrated in every study conducted in
patients with membranous nephropathy 22,32,86,125. In each
of these studies, the nadir of proteinuria in patients who
responded to immunosuppression was not reached until
at least 18 months after the start of treatment, regardless
of the type of drug. Therefore, studies of membranous
nephropathy in which the primary outcome measure is
remission of proteinuria should not have an end point
earlier than 18 months from the start of therapy. These
considerations explain why the GEMRITUX trial38 could
not have achieved its primary end point.
In the rituximab group, anti-PLA2R autoantibodies
were almost fully depleted from the circulation 3 months
after randomization, whereas the antibody titre did not
change appreciably in the control group throughout the
observation period (FIG. 3). Serum albumin concentration
increased in rituximab-treated patients at 3 months and
6 months compared with baseline, but did not change
in control patients. As previously observed with ACE
inhibitors24, the increase in serum albumin preceded
the reduction in proteinuria by months25. A post-hoc
analysis demonstrated that at 6 months, more patients
receiving rituximab than in the supportive therapy
group achieved a >50% reduction in proteinuria with
at least a 30% increase in serum albumin levels (40.5%
versus 13.2%; P <0.01)25.
Notably, the rate and timing of complete or partial
remission achieved by rituximab was similar to that pre-
viously reported with rituximab in uncontrolled series127
and also to those reported in previous trials with ster-
oid and alkylating agents at 6 months and 1 year of fol-
low up32,38. Remarkably, the safety profile of rituximab

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a b St‑Cp group than in the rituximab group (46 versus 11

P = 0.03
20 70
events, P <0.001). Moreover, 83% of the SAEs observed in
(percent change versus baseline)
Serum anti-PLA2R antibody level

Patients achieving complete or

partial remission of nephrotic
Month 3 (n = 48) Month 6 (n = 51)
0 the St‑Cp group were likely or possibly treatment-related,
60
NIAT and rituximab whereas all the SAEs observed in the rituximab group

NIAT

syndrome (%)
–20 were likely unrelated to treatment. In particular, six cases
50
–40
of cyclophosphamide-related myelotoxicity occurred in
40
addition to ten cases of hyperglycaemia, seven throm-
–60 boembolic events and one case of osteonecrosis, which
–80 30 were conceivably related to concomitant steroid ther-
apy 41. Consistent with the findings of the GEMRITUX
–100 P<0.001 P<0.01 20 trial25, the rate of infections in the rituximab group was
Figure 3 | Key findings from the GEMRITUX trial . a | Changes in serum anti-M-type
38 similar to that in the general population, and these events
phospholipase A2 receptor (PLA2R) antibody levels at 3 months Nature Reviews | after
and 6 months Nephrology were unlikely to be related to treatment, whereas infec-
patients were randomly assigned to receive nonimmunosuppressive antiproteinuric tions in steroid and cyclophosphamide-treated patients
therapy (NIAT) or NIAT plus rituximab. b | Percentage of patients achieving complete or were more likely to be severe and to result in hospital
partial remission of the nephrotic syndrome at the end of the extension period admission (11serious infections, including three fatal
(17 months). In the rituximab group, anti-PLA2R autoantibodies were almost fully depleted cases of sepsis, in addition to 37 nonserious infections).
from the circulation 3 months after randomization. The treatment effect was sustained up Moreover, three blood malignancies and five solid
to 6 months, whereas the antibody titre did not change appreciably in the control group tumours (fatal in two patients) were observed in the
throughout the observation period. By 17 months after randomization the rate of
steroid and cyclophosphamide group. All these cancers
complete or partial remission in the rituximab group was almost twice that of controls
and the between-group difference in remission rate was significant.
were thought possibly related to treatment. One cancer
was thought likely to be related to previous chlorambucil
exposure. Taken together, these findings support the well-­
therapy was similar to that of supportive therapy, a find- established carcinogenic effects of alkylating agents46,128.
ing that supports safety data from previous uncontrolled In this study, cumulative patient exposure to steroids and
studies22,23,42,65,82,83,86. cyclophosphamide exceeded the limit recommended in
the KDIGO guidelines10. According to these guidelines,
Comparative analyses with steroid and cyclophospha‑ a 75 kg patient treated with 2 mg/kg per day of cyclophos-
mide. To date, the safety and efficacy profile of rituximab phamide for 6 months would be exposed to a cumulative
compared to that of conventional therapy (steroids and dose of 27.4 g. Patients in this study received 1.5 mg/kg per
alkylating agents) has not been compared in an RCT. day of cyclophosphamide and were exposed to a cumu-
Therefore, data have been compared from two well-­ lative dose ranging from 10.2 g at 3 months to 20.5 g at
defined cohorts of patients with membranous nephro­ 6 months and, ultimately, 41.1 g at 12 months. Thus,
pathy and persistent nephrotic syndrome, 100 of whom at 6 months the administered cumulative dose of cyclo-
were treated with rituximab and 103 with a steroid plus phosphamide was within recommended range10. Higher
cyclophosphamide (St‑Cp) combination regimen, and than recommended cumulative doses might result in an
who were monitored for up to 5 years according to pre- increase in long-term adverse effects. However, in this
defined standardized protocols45,86 at two different neph- comparative analysis most adverse events (such as leu-
rology units in Europe41. Cox regression analyses adjusted kopaenia, infections, and liver toxicity) occurred within
for baseline patient characteristics showed a marked dif- 3–6 months, the period of time when patient exposure
ference in safety profiles between the two groups. Over to cyclophosphamide was within recommended limits10.
a median follow‑up of 40 months, patients in the rituxi­ Moreover, no clear dose–response relationship was found
mab group had significantly fewer adverse events than the between cyclophosphamide and malignancy in the cumu-
St‑Cp group (63 versus 173; P <0.001), with differences in lative dose range between 10 g and 40 g (REF. 46). Therefore,
terms of both SAEs (11 versus 46; P <0.001) and nonseri- the excess long-term risk of malignancies associated with
ous adverse events (52 versus 127; P <0.001). The cumula- cyclophosphamide therapy could not be fully explained
tive incidence of any first (35.5% versus 69.0%; P <0.001), by patient exposure to high cumulative doses of the drug.
serious (16.4% versus 30.2%; P <0.002), or nonserious Notably, the adverse events associated with rituximab
(23.6% versus 60.8%; P <0.001) adverse event was sig- in studies reported since 2002 (REF. 42) are less frequent
nificantly lower with rituximab. Adjusted hazard ratios and less severe than those observed with combination
between rituximab and St‑Cp groups were 0.27 (95% CI steroid and cyclophosphamide therapy, and even with
0.16–0.44) for any first adverse event, 0.32 (95% CI 0.15– ciclosporin, in trials conducted before publication of the
0.68) for SAEs, and 0.23 (95% CI 0.13– 0.41) for nonseri- Guideline for Good Clinical Practice in 1996 (REF. 36).
ous adverse events. Although the cumulative incidence of Rituximab has been shown to be remarkably safer
partial remission was lower in the rituximab group, rates than ‘traditional’ medications used for decades for the
of complete remission and the composite renal end point treatment of membranous nephropathy, despite prob-
(doubling of serum creatinine compared to baseline levels, able under-reporting of their adverse effects in non-­
development of ESRD, need for chronic renal replacement monitored trials prior to the early 1990s. Rituximab
therapy or death from any cause) did not differ signifi- might, therefore, be considered the first-line therapy for
cantly between groups. In particular, the rate of SAEs and patients with membranous nephropathy and persistent
fatal adverse events was more than fourfold higher in the nephrotic syndrome despite conservative treatment.

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Ongoing trials. The RI‑CYCLO trial will assess whether
rituximab is safer and achieves complete remission of
nephrotic syndrome more effectively than cyclical ster-
oid and cyclophosphamide combination therapy at
1 year in 70 patients with membranous nephropathy 129.
MENTOR130 and the STARMEN trial131 will assess,
respectively, whether rituximab is noninferior to ciclo-
sporin in inducing long-term remission (complete or
partial) of proteinuria132 and whether, combined with
tacrolimus, rituximab increases the rate of complete
or partial remissions and improves survival with fewer
adverse effects compared to steroids plus cyclophos-
phamide133. Of note, the patients enrolled in MENTOR
have better renal function than patients in the above-
mentioned trial from the UK33, and ciclosporin will be
administered at lower doses, which should reduce the
risk of chronic nephrotoxicity.
Rituximab and kidney transplantation
Membranous nephropathy recurs in approximately 42%
of patients who undergo kidney transplantation and
can lead to proteinuria, reduced graft function, and an
increased risk of graft failure134–138. Rituximab has been
used successfully in these patients136,139,140.
Study of post-transplantation serial, per-protocol
biopsies has led a new understanding of subclinical
disease and histology at early stages of membranous
nephropathy 139 and, importantly, has shown that rituxi­
mab therapy can result in both clinical remission and
histological resolution of disease136. Approximately
80% of patients with membranous nephropathy under-
going kidney transplantation have anti-PLA2R anti-
bodies, which seem to predict disease recurrence and
response to anti‑CD20 therapy 59,141,142. Among 63 kid-
ney graft recipients with biopsy-proven membranous
nephropathy who were observed for up to 10 years,
30 (46%) experienced a relapse that was confirmed by
early per-protocol biopsy in 16 patients140. This obser-
vational study showed that per-protocol biopsy enables
early diagnosis, before progression to severe disease.
Disease recurrence often occurred during the first year
after transplantation, although a second ‘wave’ of recur-
rences were detected by per-protocol biopsies taken at
5 years140. This observation might relate to the fact that
induction immunosuppression can result in a reduction
in anti-PLA2R antibodies early after transplantation141.
After recurrence, proteinuria did not progress in 29% of
24 patients, which is similar to the rate of spontaneous
clinical resolution of membranous nephropathy reported
in native kidneys7. Approximately 70% of patients with
recurrence of membranous nephropathy had either
high-grade proteinuria or increasing urine protein
­levels over time. Based on the assumption that patients
with proteinuria >1,000 mg per day have progressive
disease135,136, those who reached this level of proteinuria
were treated with rituximab140. Treatment achieved dis-
ease remission and histological resolution in 82% and
40% of patients, respectively, and prevented kidney graft
failure in all patients140, a remarkable change from previ-
ous experience134–138. Furthermore, the response to ther-
apy was persistent; no patient who achieved complete
remission required retreatment. No serious infections
were associated with rituximab, and only nonserious
events were observed early after treatment 140. This find-
ing is remarkable considering that patients were already
receiving triple antirejection therapy with corticoster-
oids, calcineurin inhibitors (or sirolimus in three cases),
and mycophenolate mofetil with the exception of four
patients who were on a steroid-free regimen. The highest
risk of recurrence was observed in patients with high
levels of proteinuria and, as previously reported141,142,
detectable circulating anti-PLA2R antibodies at the time
of transplantation. However, one-third of patients with-
out detectable anti-PLA2R antibodies also had disease
recurrence. In some patients, anti-PLA2R antibodies
could not be detected after transplantation despite per-
sistent glomerular PLA2R antigen staining — probably
because transplantation-related immunosuppression can
inhibit autoantibody production141 and potentially even
improve the response to rituximab23,136.
On the basis of these findings, patients with mem-
branous nephropathy who are candidates for kidney
transplantation should be advised that the cumulative
risk of disease recurrence is 50–60% over ~6 years, with
30–35% of recurrences observed during the first year
post-­transplantation140. Although 60% of membranous
nephropathy recurrences are progressive, in most cases
rituximab is effective particularly when applied early in
the disease140. Close surveillance of proteinuria, albu-
minuria, and antibody titre is advised, particularly in
patients at high risk of recurrence. Theoretically, ritux-
imab given before transplantation could prevent mem-
branous nephropathy recurrence and allograft injury 140.
If this approach is considered, rituximab should be
administered several months before transplantation
because the response to therapy is progressive over time65.
Taken together, the available data indicate that an
approach focused on early diagnosis and early B-cell
targeting therapy could substantially reduce the risk
of kidney graft loss due to membranous nephro­pathy
recurrence. In the pre-rituximab era, this risk was
reported to account for 18–20% of allograft losses143,144.
Failure of rituximab therapy
When CD20‑targeted therapy with rituximab fails (in
~25–30% of patients with membranous nephropathy
and nephrotic syndrome), the nephrologist is faced with
the dilemma of exposing the patient to toxic medica-
tions or observing the patient progress while receiving
conservative therapy. This issue is not trivial because
nephrotic syndrome substantially reduces quality of life
(particularly physical functioning) and is associated with
serious cardiovascular and thromboembolic complica-
tions. Steroids plus cyclophosphamide and calcineurin
inhibitors should be avoided owing to their associated
adverse effects. Moreover, no data are available on their
efficacy as second-line therapy for patients in whom
rituximab treatment fails. If the patient is a potential
candidate for kidney transplantation, conservative ther-
apy can be instrumental in avoiding the risk of add‑on,
adverse interactions between immunosuppression and
subsequent antirejection treatment.

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Rituximab differentiate into plasmablasts (immature plasma cells),

binding site
Ofatumumab
binding site
Large loop
B-cell
membrane Small loop
Intracellular
1 297
N-terminal C-terminal
Figure 4 | The molecular configuration of the CD20
Nature Reviews
molecule. CD20 is a tetra-transmembrane | Nephrology
protein that
essentially remains on the membrane of B cells without
dissociation or internalization upon antibody binding.
CD20 has small and large extracellular loops. The binding
sites of CD20 monoclonal antibodies, rituximab and
ofatumumab, are indicated. Rituximab binds an epitope
on the large loop only, whereas ofatumumab specifically
recognizes an epitope encompassing both the small and
large extracellular loops of the CD20 molecule.
In approximately half of patients for whom rituxi-
mab therapy fails, the lack of success can be explained
by the presence of severe and irreversible chronic renal
lesions at the time of treatment. However, in a small
but substantial subset of patients, rituximab seems to
fail because of ineffective or transient depletion of cir-
culating anti-PLA2R autoantibodies (and conceivably
anti‑THSD7A or other unknown nephritogenic auto­
antibodies)65. Some of these patients are prone to relapse.
Three groups of patients can be identified according to
their clinical outcome. First, those who primarily fail
rituximab therapy. Second, those who initially respond
to treatment but then relapse. Third, those who, after
repeated exposures to rituximab, experience treatment
sensitization or an allergic reaction that can manifest as
resistance to treatment or symptoms resembling serum
sickness (for example, arthritis, arthralgias, myalgia,
and fever), which contraindicate further exposure to the
drug. With primary treatment failure and relapse, novel
treatments are needed to achieve antibody depletion by
mechanisms different from, or complementary to, those
of rituximab. In patients with sensitization or allergic
reaction to treatment, humanized monoclonal anti­
bodies that bind the CD20 antigen similarly to rituximab
without inducing any immune response may be useful145.
Autoantibodies against PLA2R, THSD7A, or other
unknown antigens, can be produced by two distinct anti-
body-producing cell populations146: short-lived plasma
cells and long-lived memory plasma cells. Short-lived
plasma cells are usually generated in the spleen and lymph
nodes from activated B cells. As observed after vaccina-
tion or during episodes of immune-mediated disease,
these cells proliferate upon exposure to antigens and
which invade the peripheral circulation, produce anti-
bodies, and further differentiate into mature, short-lived,
nonproliferating plasma cells. Activated B-cell clones,
however, can be disrupted by nonspecific immuno­
suppressants, such as steroids and alkylating agents, as
well as by anti‑B-cell antibodies, such as rituximab and
ofatumumab, which have a direct cytolytic effect. Other
antibodies, such as belimumab, can block growth factors
and mediators of B‑cell proliferation and differentiation
(discussed in further detail below). After disruption or
inhibition of the autoreactive clones, the plasma cell pool is
no longer fueled; short-lived plasma cells disappear within
a few days of treatment and are no longer replenished.
By contrast, memory plasma cells are resistant to
conventional immunosuppression and B‑cell targeted
intervention. These cells secrete antibodies independent
of antigen contact or interactions with B cells and T cells
and are involved in chronic humoral autoimmunity and
treatment-refractory disease. The memory cell pool can
also be enriched by plasmablasts, which invade survival
niches in the bone marrow, lymph nodes, and inflamed
tissue where they transform into long-lived memory
plasma cells to sustain autoantibody production and
chronic inflammation. Speculatively, upon re‑exposure
to antigens, memory cells could reactivate into plasma-
blasts and then convert to plasma cells to produce large
numbers of antibodies147.
In patients with membranous nephropathy, therefore,
newly generated, short-lived plasmablasts attributable to
B-cell hyperactivity are likely to produce the majority of
autoantibodies at disease onset and at the time of relapse,
whereas memory plasma cells produced as a result of
autoreactive B-cell activation can sustain autoantibody
production despite therapy or disease relapses after initial
remission. Conceivably, both pathways might contrib-
ute differently to autoantibody production in different
patients and at different stages of the disease. Failure to
achieve autoantibody depletion and disease remission
can, therefore, be explained by two mechanisms that are
not mutually exclusive — changes in the CD20 antigen
that prevent B cell–rituximab binding and B-cell deple-
tion, and autoantibody production by long-lived memory
plasma cells that do not express the CD20 antigen148.
Ineffective autoreactive B‑cell depletion. The cytotoxic
B-cell effect of rituximab seems to be mediated by its
specific binding to the large loop of the CD20 antigen
(FIG. 4) with secondary C1q capture, complement depo-
sition on B-cell membranes, and complement-mediated
cytolysis. The B-cell surface antigen, CD20, is a tetra-­
transmembrane protein involved in the phosphorylation
cascade of intracellular proteins and B-cell activation,
proliferation, and differentiation149. This protein pro-
trudes from the surface of the B-cell membrane into
the extracellular space by a small loop and a large loop,
which are binding sites for anti‑CD20 monoclonal anti-
bodies85,150–152 (FIG. 4). As observed in treatment-­resistant
B-cell lymphomas, some B cells become resistant to
rituximab-induced complement-dependent cytotoxicity
because of changes or internalization of the large loop of

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 REVIEWS

the CD20 antigen, which prevents rituximab binding to
its specific epitope. To overcome this limitation of rituxi­
mab therapy, second and third generation anti‑CD20
monoclonal antibodies, such as obinutuzumab and
ofatumumab, have been developed that bind different
epitopes on the CD20 antigen. These agents have been
proven effective for the treatment of B‑cell lymphomas153
(with some exceptions154) and other blood malignan-
cies155 in patients who had previously failed rituximab
therapy. Ofatumumab, unlike rituximab, specifically rec-
ognizes an epitope encompassing both the small and large
extracellular loops of the CD20 molecule156 (FIG. 4), which
seems to be closely related to effective C1q capture and
complement-­mediated cytotoxicity 155. The close binding
proximity of ofatumumab to the cell membrane is likely to
result in more efficient complement deposition on B‑cell
membranes than achieved with rituximab, which might
explain the cytotoxic effects of this agent on rituximab-re-
sistant B cells. Ofatumumab was approved by the FDA in
2009 and the European Medicines Agency in 2010 for the
treatment of chronic lymphocytic leukaemia157 and could
have additional indications for some non-Hodgkin lym-
phomas and relapsing–remitting multiple sclerosis and
rheumatoid arthritis158. In 2014, ofatumumab was found
to achieve complete disease remission in four children
and a 19‑year old girl with focal segmental glomeru-
losclerosis or minimal change disease ­associated with
­rituximab-resistant nephrotic syndrome159.
In patients with rituximab-resistant membranous
nephropathy, rituximab fails to persistently deplete cir-
culating autoantibodies, but achieves the same deplet-
ing effect on circulating B cells that is observed in
rituximab-­sensitive patients65. Therefore, changes in
the CD20 antigen that prevent rituximab binding might
be restricted to autoreactive B-cell clones that continue
to produce nephritogenic antibodies despite depletion
of the large majority of ‘innocent’ circulating B cells.
Box 2 | Ofatumumab as rescue therapy in membranous nephropathy
A 30‑year-old male patient who had failed a course of steroid and cyclophosphamide
according to KDIGO guidelines, achieved complete B‑cell depletion and proteinuria
remission following a single infusion of 375 mg/m2 of rituximab. After five relapses that
invariably recovered after rituximab administration, the last rituximab infusion was
ineffective. The outcome was complicated by fever and arthralgias, which were
interpreted as signs of a serum-sickness-like syndrome. Circulating B cells were fully
depleted after each rituximab infusion. He subsequently received one infusion of 300 mg
per m2 of body surface area of ofatumumab155 which, as previously observed with one
375 mg/1.73m2 infusion of rituximab119, achieved full B‑cell depletion within 24 h.
Proteinuria progressively decreased up to complete remission of nephrotic syndrome
over approximately 10 months. 18 months after administration of ofatumumab he was
well, without proteinuria. A second patient who had failed a 6‑month steroid and
clorambucil course followed by 1-year ciclosporin therapy, received one infusion of
375 mg/m2 of rituximab. Despite depletion of circulating CD20 cells, proteinuria
continued to increase up to 15 g per 24 h and serum creatinine to 3.5 mg/dl
(309.4 μmol/l). 300 mg of ofatumumab was subsequently infused. Treatment fully
depleted B cells from the circulation within 24 h, achieved complete and persistent
remission of nephrotic syndrome within 10 months, and even decreased serum
creatinine to pre-rituximab levels. 1‑year later the patient was well, without proteinuria
and with near-normal serum creatinine levels. Thus, ofatumumab is a promising
alternative to rituximab and, cost effective, given that 300 mg of ofatumumab for a 70 kg
patient costs €1,193 compared to €3,206 for 700 mg of rituximab120.
Ofatumumab has been assessed as rituximab rescue
therapy in eleven patients with membranous nephro­
pathy and without advanced renal insufficiency, and this
preliminary experi­ence is encouraging (P. Ruggenenti
and G. Remuzzi; unpublished work; BOX 2). Blockade of
factors or cells that stimu­late autoreactive B cells, such
as type I interferon, T-helper cells, or regulatory T cells,
might also prevent the development of short-lived plas-
mablasts and plasma cells160 (TABLE 2). A monoclonal anti-
body, belimumab, specifically targets the soluble form of
B lymphocyte stimulator (BLyS, also known as BAFF),
a tumour necrosis factor super family ligand that has a
critical role in the differentiation and homeostasis of B
lymphocytes. Via BLyS inhibition, belimumab might
induce apoptosis and depletion of autoreactive B cells.
The effects of belimumab on proteinuria and anti-PLA2R
antibody production were evaluated in 14 patients with
anti-PLA2R-positive membranous nephropathy and a
urinary protein:creatinine ratio >400 mg/mmol from six
centres in the UK161. Treatment significantly and progres-
sively decreased anti-PLA2R antibody titre by week 12,
and reduced proteinuria together with normalization of
serum albumin levels in patients with overt nephrotic
syndrome. Of note, changes in anti-PLA2R antibody
titre and in proteinuria seemed to parallel the changes
observed after rituximab administration, but with an
apparent delay of approximately 3–6 months (FIG. 5).
Conceivably, the faster effect of rituximab reflected
immediate B-cell lysis, whereas the delayed effect of
belimumab might reflect progressive ‘exhaustion’ of
antibody-producing B cells secondary to BLyS binding
and inhibition. Considering the different mechanisms
of B-cell inhibition, rituximab and belimumab given in
combination could synergistically inhibit autoreactive
B-cell clones162 and achieve faster and more efficient
inhibition of autoantibody production than rituximab
or belimumab monotherapy.
New therapeutic options to inhibit the production of
autoantibodies could include interventions that specif-
ically target the autoreactive B-cell clones involved in
the production of anti-PLA2R or anti‑THSD7A auto­
antibodies, peptides that interact with the antibodies, or
antibody traps or decoys2,163.
Insights to aid the development of more targeted
therapeutic approaches for the treatment of auto­
immune disease might be gleaned from a 2016 study
of pemphigus vulgaris, an autoimmune disease of the
skin mediated by IgG autoantibodies against desmo-
glein 3 (REF. 164). Using an in vivo model of the disease,
researchers have engineered T cells to specifically rec-
ognize B cells that secrete anti-desmoglein 3 antibodies,
enabling their precise and efficient disposal164. Although
in its infancy, this pioneering approach could also ena-
ble antigen-specific immunosuppression in other B cell-­
mediated autoimmune diseases for which autoantigens
have been identified, such as membranous nephropathy.
Targeting memory plasma cells. Whether early-stage
membranous nephropathy is predominantly mediated
by autoreactive B-cell clones sensitive to B‑cell targeted
therapy, whereas more advanced disease is mediated by

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a b Four 1.3 mg/m2 doses of bortezomib administered sub-

cutaneously at weekly intervals decreased autoantibody

Anti-PLA2R antibody titre (mean

percent change versus baseline)
percent change versus baseline)
ratio or 24 h proteinuria (mean

50 Rituximab 50 production and disease activity in 12 patients with cyclo-

Urinary protein to creatinine

Belimumab phosphamide and rituximab-resistant SLE170 and in one

0 0
–50 –50
–100 –100
0 3 6 9 12 18 24 0 3
Months
Figure 5 | Comparison of outcomes with belimumab or rituximab therapy.
a | Percentage change in urinary protein to creatinine ratio Nature
(or 24 hReviews
proteinuria) versus
| Nephrology
baseline. b | Percentage change in anti-M-type phospholipase A2 receptor (PLA2R)
antibody titre versus baseline. Data are from patients with membranous nephropathy
and nephrotic syndrome treated with belimumab (n = 14) or rituximab (n = 132)61.
Belimumab specifically targets the soluble form of B lymphocyte stimulator (BLyS,
also known as BAFF)161. Changes in proteinuria and anti-PLA2R antibody titre after
belimumab treatment seemed to parallel the changes observed after rituximab
administration albeit with a delay in onset. Conceivably, the faster reduction in
proteinuria and anti-PLA2R antibody titre after rituximab administration reflected the
immediate B-cell lysis achieved by treatment, whereas the slower effect of belimumab
might reflect the progressive ‘exhaustion’ of antibody-producing B cells secondary to
BLyS binding and inhibition.
autoreactive memory plasma cells resistant to anti-CD20
monoclonal antibodies but sensitive to anti‑CD38 anti-
bodies or proteosome inhibitors, is unknown. Moreover,
whether transition from a process predominantly medi-
ated by B cells to one that is predominantly mediated by
plasma cells is, to some extent, associated with epitope
spreading and the development of anti‑CTLD1 and
anti‑CTLD7 autoreactivity is also unknown, but is an
intriguing proposal that might explain why patients with
epitope spreading do not benefit from B cell-­targeted
therapy. Memory plasma cells survive rituximab ther-
apy because they do not express the CD20 antigen and
continue to produce autoantibodies despite effective
B‑cell depletion from the circulation148,165. Plasma cells,
however, strongly express CD38, a multifunctional cell
surface protein that is expressed at low levels in other
blood cells and solid tissues166. CD38‑positive plasma
cells can enrich chronically inflamed tissues and secrete
autoantibodies165. Autoreactive plasma cells could there-
fore be a target for anti‑CD38 monoclonal antibodies,
such as daratumumab and isatuximab. Like anti‑CD20
antibodies that were initially introduced for the treatment
of B‑cell lymphomas, these agents have been developed
to kill malignant plasma cells166 and could be tested in
patients with plasma cell-mediated autoimmune diseases,
including some forms of membranous nephropathy.
Other molecules, such as the proteasome inhibitor
bortezomib, have been reported to effectively deplete
plasma cells, particularly activated plasma cells that,
during forced production of circulating autoanti­bodies,
are exposed to unfolded protein accumulation and
consequent apoptosis167. Bortezomib depletes auto­
reactive plasma cells and reduces ANCA and anti-double
stranded DNA antibody titres in experimental models
of ANCA-associated nephritis168 or lupus nephritis169.
patient with ANCA-associated vasculitis171. Bortezomib
has also been shown to prevent donor-specific antibody
production in kidney transplant recipients with anti-
body-mediated rejection172. A patient with membranous
nephropathy who had failed 6‑month treatment with
high-dose steroids achieved complete remission of the
6 9 12 18 24 nephrotic syndrome with bortezomib173, and another
Months patient with rituximab-resistant, post-transplantation
recurrent membranous nephropathy who was treated with
bortezomib achieved depletion of circulating CD34+ and
CD138+ cells and progressively reduced proteinuria over
1 year 147. These findings indicate that plasma cells might
be involved in the pathogenesis of primary and recurrent
membranous nephropathy, particularly among patients
in whom anti‑CD20‑depletion therapy is not successful.
Unfortunately, bortezomib has serious adverse effects,
such as infections and neurotoxicity, which necessitate
treatment interruption in most patients. The develop-
ment of second-generation proteasome inhibitors that
are as effective and safer than bortezomib, such as delan-
zomib and carfilzomib, will hopefully pave the way for
RCTs to evaluate the risk:benefit profile of this novel
therapeutic option in patients with rituximab-resistant
membranous nephropathy.
Polyclonal antithymocyte globulins (ATGs) are often
used in induction immunosuppressive protocols to pre-
vent rejection of solid allografts or autologous haemato-
poietic stem cells. ATGs bind to antigens such as CD38,
CD138, and CD52, which are expressed on plasma
cells, including autoreactive memory plasma cells174. In
patients with severe autoimmune diseases refractory to
conventional immunosuppression, ATGs could achieve
complete and sustained remission. The process would
involve an ‘immunoablation’ followed by the reconstitu-
tion of an ‘adapted’ immune system devoid of autoreactive
long-lived memory plasma cells and which is, therefore,
self-tolerant175. This immunoablation might explain why
treatment-resistant membranous nephropathy does not
recur in many patients who have undergone kidney trans-
plantation, and why anti‑CD20 targeted therapy achieves
remission of membranous nephropathy in patients with
kidney grafts more effectively than in native kidneys.
Unfortunately, the potentially devastating effects of even
a transient ablation of the immune system do not seem
to justify this therapeutic approach for the treatment of
membranous nephropathy. More-selective approaches
under investigation explore the possibility of inhibiting
adhesion molecules, which contribute to plasma cell
homing and survival in the bone marrow niche and
recruitment of inflammatory cells into the bone marrow
or inflamed tissue. Ideally, novel drugs should specifically
disrupt autoreactive plasma cells without affecting plasma
cells that secrete protective antibodies146.
Targeting complement. Complement is activated by anti-
body interaction with target antigens on the podocyte
and at least part of the glomerular injury initiated by this

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interaction is complement-mediated (FIG. 2). Complement
could, therefore, be another target for the treatment of
membranous nephropathy. One, unfortunately unpub-
lished, prospective, randomized, clinical trial did not
demonstrate any antiproteinuric effect of 4 month ecu-
lizumab therapy (8 mg/kg every 2 or 4 weeks) compared
to placebo in 117 patients with membranous nephro­
pathy. The results of the study were, however, incon-
clusive because underdosing of eculizumab resulted in
ineffective complement inhibition176. Novel complement
inhibitors including oral agents, recombinant proteins,
small molecules, new monoclonal antibodies, small
interfering RNA agents, and approaches that upregulate
natural complement inhibitors will become available for
clinical use in the near future. These agents are likely
to be evaluated in new trials of complement-targeting
interventions, particularly in patients with membranous
nephropathy and nephrotic syndrome in whom CD20
targeted therapy fails163,177,178.
Conclusions
Over the past decade, major advances in the understand-
ing of the mechanisms of membranous nephropathy have
led to novel perspectives on treatment. The integrated
evaluation of serum autoantibody titre and proteinuria,
together with serum albumin levels in patients with overt
nephrotic syndrome could guide diagnosis of membra-
nous nephropathy and individually tailored treatment
protocols. Conventional, nonspecific, and toxic immuno-
suppressive regimens will become treatments of the past6,
to be replaced by more disease-specific and safer medica-
tions, such as B cell-targeting monoclonal antibodies and
autoreactive plasma cell inhibitors, paving the way for a
novel therapeutic paradigm based on the principles of
precision medicine and personalized therapy 9. Complex
predictive models to identify which patients to treat and
when179 will no longer be needed, and even the most frail
patients with severe disease might benefit from new, safe
therapeutic options. Treatment could be anticipated at
earlier and milder stages of membranous nephropathy,
even before the onset of nephrotic syndrome, to pre-
vent chronic and potentially irreversible histological
changes78. Patients who were previously left untreated,
so as not to expose them to the toxicity of cyclophospha-
mide, might benefit from B cell-targeted therapy, which
can prevent memory cell clone expansion associated with
uncontrolled disease progression towards disease that is
refractory to currently available therapy 146.

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Acknowledgements
Luca Perico, Istituto di Ricerche Farmacologiche Mario Negri,
Bergamo, Italy, helped to revise the paragraph on PLA 2R
epitope spreading and FIG. 2.
Author contributions
P.R. and F.C.F. researched data for the article. All authors
contributed to discussion of the article’s content, writing and
review/editing the manuscript before submission.
Competing interests statement
F.C.F. has received unrestricted research grants from
Genentech/Roche, the maker of rituximab. The other authors
declare no competing interests.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

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