Clinical Immunology 237 (2022) 108976

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Clinical Immunology
journal homepage: www.elsevier.com/locate/yclim

Review Article

Revisiting immunological and clinical aspects of membranous nephropathy

Israel Nieto-Gañán a, 1, *, Ignacio Iturrieta-Zuazo a, b, 1, Claudia Rita a, Ángela Carrasco-Sayalero a
a
Immunology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
b
Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain

A R T I C L E I N F O A B S T R A C T

Keywords: Idiopathic or primary membranous nephropathy (IMN) is one of the most frequent causes of nephrotic syndrome
Glomerulonephritis in adults and the elderly. It is characterized by a thickening of the wall of the glomerular capillaries due to the
Membranous nephropaty presence of immune complex deposits. 85% of membranous nephropathy cases are classified as primary or
Anti-PLA2R
idiopathic (IMN). The rest are of secondary origin (SMN), caused by autoimmune conditions or malignant tumors
Thrombospondin type I domain-containing 7A
as lung cancer, colon and melanomas. It is an organ-specific autoimmune disease in which the complement
Immunopathogenesis
Diagnosis system plays an important role with the formation of the membrane attack complex (MAC; C5b-9), which
Epidemiology produces an alteration of the podocyte structure. The antigen responsible for 70-80% of IMN is a podocyte
Treatment protein called M-type phospholipase A2 receptor (PLA2R). More recently, another podocyte antigen has been
identified, the “Thrombospondin type-1 domain-containing 7A” (THSD7A), which is responsible for 10% of the
cases of negative IMN for anti- PLA2R.

1. Introduction It is an organ-specific autoimmune disease in which the complement

The term glomerulonephritis (GN) is used to designate diseases that
affect the structure and function of the glomerulus, although the other
structures of the nephron may later be involved. We speak of primary
GN when the renal involvement is not the consequence of a more general
disease and the clinical manifestations are restricted to the kidney.
Conversely, we talk of secondary GN when is due to a systemic disease.
Idiopathic or primary membranous nephropathy (IMN) constitutes
one of the most frequent causes of nephrotic syndrome in adults and the
elderly, while it is rare in children and adolescents. It is characterized by
a uniform and diffuse thickening of the wall of the glomerular capil­
laries, without associated cell proliferation. This thickening is due to the
presence of immune complex deposits along the capillary wall. It usually
progresses slowly. 85% of membranous nephropathy cases are classified
as primary (IMN), that is, the cause of the disorder is idiopathic or un­
known. The rest are of secondary origin (SMN), caused by autoimmune
conditions (systemic lupus erythematosus, infections (syphilis, malaria
and hepatitis B), drugs (captopril and NSAIDs), inorganic salts or ma­
lignant tumors as lung cancer, colon and melanomas.
system plays an important pathogenic role after the formation of im­
mune complexes, when antibodies bind directly to antigens on the
podocyte membrane. After the formation of the membrane attack
complex (MAC; C5b-9) there is alteration of the podocyte structure and
distortion of its slit diaphragms, causing the appearance of massive
proteinuria [1].
In recent years, it has been possible to identify podocyte antigens
responsible for most cases of IMN. The antigen responsible for 70-80% of
IMN is a podocyte protein called M-type phospholipase A2 receptor
(PLA2R). The antibodies formed against this protein are mainly of the
IgG4 isotype [2]. The mechanisms that trigger these autoimmunity
processes are unknown. Recent studies have shown a genetic predispo­
sition to the disease associated with certain HLA alleles and the genes
that encode PLA2R [3]. More recently, another podocyte antigen has
been identified, the “Thrombospondin type-1 domain-containing 7A”
(THSD7A) against which a similar autoimmune process is triggered and
which is responsible for 10% of the cases of negative IMN for anti-
PLA2R [4].
The determination of anti-PLA2R has represented a great advance in

Abbreviations: BSA, Bovine serum albumin; GN, Glomerulonephritis; GBM, Glomerular Basement Membrane; ESRD, end-stage renal disease; MAC, Membrane
Attack Complex; MN, Membranous Nephropathy; PLA2R, M-type phospholipase A2 receptor; IMN, Primary Membranous nephropathy; THSD7A, Thrombospondin
type-1 domain-containing 7A.
* Corresponding author.
E-mail address: Israel.ganan@salud.madrid.org (I. Nieto-Gañán).
1
These authors contributed equally.

https://doi.org/10.1016/j.clim.2022.108976
Received 3 September 2021; Received in revised form 16 February 2022; Accepted 5 March 2022
Available online 9 March 2022
1521-6616/© 2022 Elsevier Inc. All rights reserved.
I. Nieto-Gañán et al.
the rapid differential diagnosis of MN. Several authors consider that the
positivity of anti-PLA2R is always diagnostic of IMN, even though other
conditions coexist in the patient (for example, tumors or infectious
diseases) that could theoretically be responsible for the process. The
detection of anti-THSD7A requires a deeper search for a tumour process
in MN patients, since several cases of MN anti-THSD7A positive with
associated tumour have been published [5].
Next we will address the epidemiology, clinical aspects, immuno­
pathogenesis, diagnosis and treatment of this disease.
2. Epidemiology
MN is the most common cause of idiopathic nephrotic syndrome in
nondiabetic caucasian adults over 40 years worldwide [6]. Although
discrepancies are observed between the different series studied, it is
accepted that it represents around 30% of the cases, increasing to 40% in
the elderly [7]. However, studies in the pediatric population show that it
is a rare entity, being responsible for 4-5% of cases of infantile nephrotic
syndrome [8]. In addition, MN is one of the leading causes of primary
glomerulonephritis, occupying the second or third position according to
the series studied [9]. Furthermore, is the main glomerulopathy in terms
of recurrence after kidney transplantation (about 40% of patients)[10].
Globally, the estimated incidence rate is about 1,2/100.000 per year,
with a mean age between 45 and 60, progressively increasing with age
[6]. Significant differences have been found by ethnicity, being more
common in Caucasians, followed by Asians, and less frequent in Blacks
and Hispanics [10]. Some authors have also found differences between
genders, being more frequent in men than in women (2:1) [9].
3. Clinical aspects
IMN is renal limited and his autoimmune nature has been known for
some years, after the identification of IgG autoantibodies, predomi­
nately IgG4, deposited in a podocyte receptor (phospholipase A2 re­
ceptor, PLA2R) in approximately 75% of cases [11]. More recently, a
second podocyte antigen called thrombospondin type 1 domain con­
taining 7A (THSD7A) was identified in a smaller number of patients with
IMN [4]. In this respect, some authors consider that the term idiopathic
MN should be replaced by autoimmune MN [12].
In secondary MN, kidney damage occurs due to the formation of
immune complexes at the glomerular level in the context of systemic
diseases or exposure to substances or microorganisms, which are
responsible for the antigens involved in the formation of these immune
complexes. There are numerous entities that are associated and can
trigger a secondary MN: systemic diseases (systemic lupus erythemato­
sus, sarcoid, thyroiditis, diabetes and rheumatoid arthritis), tumors
(lung, colon and prostate)., infections (hepatitis B and C and HIV), drugs
(d-penicillamide, gold salts and non-steroidal anti-inflammatories)
[10,13].
Clinically, most patients with nephrotic syndrome present: protein­
uria above 3.0g/24h, edema, hypoalbuminemia, hyperlipidemia,
normal or slightly altered kidney function and normal blood pressure
[14], which facilitates its early diagnosis. Non-nephrotic proteinuria is
detected in approximately 15% of cases and the diagnosis can, unfor­
tunately, be delayed due to the absence of symptoms. For some authors
that implies that the incidence is probably underestimated. Other less
frequent signs may include arterial hypertension, lipiduria, hypona­
tremia, microhematuria and anemia. [7].
Complications are typically those derived from a nephrotic syn­
drome: Thrombophilia, or hypercoagulability disorders (in some cases,
the first manifestation of the disease may be a vein thrombosis or even a
pulmonary embolism as a consequence of this [7], increased suscepti­
bility to infections, pulmonary edema, acute kidney failure, Hypothy­
roidism, Hypocalcaemia, Vitamin D deficiency and malnutrition.[15].
The clinical course is variable, one-third of patients will have a
spontaneous remission, particularly, in those patients who never have
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Clinical Immunology 237 (2022) 108976
nephrotic range proteinuria [16] but approximately 60% of untreated
patients will end up developing progressive loss of renal function[17].
The remainder develops non-progressive chronic kidney disease. In
addition, in 30-40% of cases, it leads to end-stage renal disease (ESRD)
within 5–15 years [8]. Around 10 to 50% of patients have high blood
pressure, which has been linked to the development of chronic kidney
failure [18]. Other known risk factors are age, male sex, and decreased
glomerular filtration rate at diagnosis [7].
4. Immunopathogenesis
MN is a typical organ-specific autoimmune disease that affects the
kidney glomerulus, being the main target the glomerular cells (podo­
cytes). It involves the formation of subepithelial immunocomplexes
deposits that result in complement activation and podocyte damage
[19–21].
IMN is characterized by light microscopy by thickening of the
glomerular basement membrane (GBM) with spike formation. Immu­
nofluorescence shows fine granular deposits of IgG, complement C3, and
terminal complement complex C5b-9. Finally, electron microscope re­
veals a subepithelial electron-dense deposits (Fig. 1).
The immunopathogenesis of IMN is multifactorial, involving pre­
disposing environmental and genetic factors [22,23]. Neither is clear
why the disease is restricted to the kidney, as PLA2R and other antigens
characteristic of the disease are expressed in multiple organs [24]. It has
been suggested that differences in glycosilation or other post-
translational modifications or the facility of autoantibodies to reach
the antigen could influence in the injury to specific organs [25,26].
One of the main challenges understands how some patients presents
spontaneous remission while others lead to kidney failure. In this regard
it has been seen that patients with IMN had lower percentage of regu­
latory CD4+ T cells at baseline compared with healthy controls [27].
There is less data about patients with spontaneous remissions.
So knowledge of the immunopathogenesis of IMN and its etiology in
each individual is essential to understand the clinical evolution of the
disease and to evaluate the most appropriate treatment in each case.
4.1. Main experimental models in MN
Two models have contributed mainly to our knowledge of the
pathogenesis of IMN: Heymann nephritis model and Cationic Bovine
serum albumin (BSA) model.
First experiments on Heymann nephritis [28–30] were performed
about 50 years ago in rats. In these studies, it was concluded that the
disease was caused by the deposition of subepithelial immunocomplexes
consisting of the binding of circulating antibodies to antigens that are
part of the podocyte membrane. Kerjaschhki and Farquhar (1982, 1983)
detected that target protein in rats was megalin, belonging to the low
density lipoprotein receptor superfamily, specifically in a epitope
located in a small glycosilated N-terminal fragment [31].
The binding of circulating anti-megalin antibodies to surface megalin
induces complement activation with generation of the membrane attack
complex (MAC). This leads to the podocyte injury through structural and
functional changes as calcium influx, oxidative injury, production of
arachidonic acid metabolites, endoplasmic reticulum stress, cell cycle
dysregulation, disruption of the actin cytoskeleton, and alterations in
the ubiquitin-proteasome system. The loss of the cytoskeleton structure
induces loss and displacement of slit diaphragm structures, leading to a
profound non-selective proteinuria. The injured podocyte also produces
new extracellular material assembled between the immune deposits,
giving rise to the characteristic “spikes” and GBM thickening [32,33]
(Fig. 2).
However, although megalin is also expressed in human podocytes
[34], deposits of megalin and circulating antibodies against it have not
been described in patients with IMN.
An alternative model was described in rabbit by Border et al. [24] by
I. Nieto-Gañán et al. Clinical Immunology 237 (2022) 108976

Fig. 1. Different microscopy images on IMN. A- Glomerulus showing the typical “spikes” of basement membrane projecting from the outer surface of the glomerular
basement membrane (arrows) when stained with silver-methenamine (×40). (Provided by Dr. Charles Alpers, Department of Pathology, University of Washington,
Seattle, WA.). B- Immunofluorescence microscopy in IMN. Finely granular staining for IgG, predominately IgG4, present uniformly in a subepithelial distribution in
all glomeruli (×40). C-Electron microscopy image showing subepithelial electron-dense deposits in a patient with IMN (yellow arrows). Adapted from https://www.
kidneypathology.com/English_version/Membranous_GN.html. D-Glomerular deposition of antipPLA2r antibodies by immunoperoxidase in renal biopsy; 200x.

Fig. 2. Scheme of Heymann nephritis model of MN. (A) The normal podocyte structure is maintained by a actin cytoskeleton that also anchor the foot processes to
the GBM through adhesion complexes and cell-matrix adhesion molecules. The normal filtration slit diaphragm forms a barrier to albumin and is linked to the actin
cytoskeleton via a complex of proteins. (B) In the Heymann nephritis model antibody binding to megalin activates complement leading to formation of the MAC. This
disorganizes the dissolution of the actin cytoskeleton, which displaces the filtration slit diaphragms allowing free passage of albumin into the urine. Also affects cell-
matrix adhesion and cause flattening of the podocyte foot processes. Adapted from Cybulsky et al. (2005).

injection of cationized BSA as exogenous antigen testing the hypothesis
that only antigen with positive charge influence in the immunocomplex
deposition, since the glomerular membrane is negatively charged.
4.2. Endogenous antigen
The relevance of these experimental models above described in
human pathology was confirmed by the identification of the endogenous
antigen neutral endopeptidase (NEP) and phospolipase A2 receptor
(PLA2R) serving as target of circulating antibodies in the neonatal and

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I. Nieto-Gañán et al.
adulthood respectively. In addition, a new antigen involved in the dis­
ease has recently been discovered, THSD7A. Finally, it is probably that
new target antigens for the disease may be discovered in the future.
Complement activation by immunocomplex deposits has been consid­
ered the main cause of podocyte injury in IMN [33]. However, it cannot
be ruled out that the binding of the autoantibodies to their respective
antigens interrupts the biological function of the latter, also contributing
to the development of the disease.
- Neutral endopeptidase antigen (NEP): Was described in a neonate with
respiratory distress and acute renal failure followed by proteinuria
and hypertension, being MN the final diagnosis [35]. This rare dis­
ease called “maternal-fetal alloimmunization with antenatal MN” is
due to the presence of maternal antibodies that cross the placenta
and bind to NEP in fetal glomerular podocytes [35,36]. NEP appears
in the S-shaped body (glomerulus precursors) and persists in the
mature kidney [37,38]. However, in the above described case,
mother lacked NEP despite healthy condition; so antibodies pro­
duction could have occurred after exposition to the paternal NEP on
syncytiotrophoblastic cells [35].
Lack of NEP appears to be influenced by genetic factors. NEP is
encoded by the MME gene (membrane metallo-endopeptidase; also
called EC 3.4.24.11, neprilysin, enkephalinase, CD10, CALLA)
composed of 24 exons on the chromosome 3. All immunized mothers
lacked NEP enzymatic activity by truncating mutations located in
exons 7 (in all cases described) and 15 (only in one case) [39–41].
However, severity of the renal disease was variable, depending on
the mother`s antibody response. It has been described that only the
presence of anti-NEP IgG1 isotype is responsible for the development
of the disease [39–41]. These autoantibodies can inhibit the enzy­
matic activity causing persistence of vasoactive peptides responsible
for the ischemic injury [41]. Renal function usually improves in post-
natal life when contact with maternal IgG circulating is stopped,
reason why many cases of NEP-MN go undetected.
In the cases described, anti-NEP antibodies of the IgG1 and IgG4
subtypes have been found, so that while in cases where anti-NEP
igG4 are produced, a rapid regression of the symptoms is observed,
in those cases in which complement-fixing anti-NEP IgG1 is devel­
oped, a severe disease requiring peritoneal dialysis and even kidney
transplantation is produced [41]. In any case, screening of families is
essential because this disease could lead to chronic renal failure in
adulthood with needed renal transplant and subsequent pregnancies
would have high risk for the fetus [42]. NEP is involved in the
catabolism of regulatory peptides with vasoactive properties and also
participates in the blocking of peptide signalling events at the cell
surface [43]. Injurious effects of anti-NEP antibody might be related
to blockade of enzymatic activity that affects glomerular hemody­
namic and endothelial permeability [35,41].
- PLA2R antigen: Is the main autoantigen in adult IMN [11]. Type-M
phospholipase A2 receptor (PLA2R) was identified by mass spec­
trometry as a 185kD protein present in normal human glomerular
podocytes. IMN involves the formation of subepithelial deposits of
circulating anti-PLA2R IgG4 autoantibodies binding to podocyte
PLA2R in about 70%-80% of patients [11]. It has been seen a path­
ogenic function of these antibodies by early recurrence of MN in
kidney transplant recipients with circulating anti-PLA2R autoanti­
bodies. However, some patients with high antibodies titers do not
relapse. Also, it is unknown if anti-PLA2R antibodies start the disease
or are preceded of others factors. Thus, further studies are necessary
to find out the specific role of antibodies in the pathogenesis of the
disease [44–47].
PLA2R is a member of the mannose receptor family as well as the
cation-dependent mannose-6-phosphate receptor, the C-type
mannose receptor 2, the dendritic cell receptor DEC-205, and the
avian yolk sac IgGY receptor FcRY [48,49].
All are transmembrane proteins with N-terminal cysteine rich
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Clinical Immunology 237 (2022) 108976
(CysR, or ricin B) domain, a single fibronectin type-2 (FnII) domain,
and eight to ten C-type lectin-like domains (CTLD). Their cyto­
plasmic domains contain motifs that enable constitutive endocytic
recycling in clathrin-coated pits [50] (Fig. 3A).
All of them recirculate between the plasma membrane and the
endosomes and present at least two pH dependent configurations: an
extended configuration (N-terminal cysteine-rich domain pointing
outwards from the cell surface) and a bent configuration (N-terminal
domain folds back to interact with C-type lectin-like domains at the
middle of the structure). Although more studies in molecular
modeling of PLA2R are needed, this seems important because the
target epitope for circulating antibodies might be accessible in only
one of these configurations [51]. In fact, this conformational change
seems necessary to allow binding at physiologic pH and release in the
more acidic pH of endosomes and lysosomes, before return to the cell
surface. However, biological function of this is unknow [52].
Anti-PLA2R antibodies bind mainly with the CysR domain of
PLA2R receptor [52,53], although CTLD1 and CTLD7 also can be
ligand points[53]. In fact, patients with autoantibodies that bind to
the three domains had worst evolution than patients with antiPLA2
ab that only join to the CysR domain [54].
The binding of anti-PLA2 antibodies to the PLA2 receptor located
in the podocyte foot processes activate the complement with for­
mation of the MAC that causes the injury of the podocyte with
disorganization of the actin skeleton as well as of the cellular adhe­
sion molecules (Fig. 4).
Binding of anti-PLA2R antibodies to PLA2R receptor on podocytes
could alter receptor function. In normal conditions, binding of sol­
uble PLA2 (sPLA2) to its receptor has both positive and negative
functions (Table 1).
- Thrombospondin type I domain-containing 7A: THSD7A was identified
by western-blotting and mass spectrometry as a 250-kDa protein
[59]. It is not a member of the mannose receptor family as PLA2R. It
is a large transmembrane glycoprotein characterized by the presence
of multiple thrombospondin type-1 repeats (TSRs), which alternate
between group 1 and group 2 differing in the position of three
intradomain disulphide bonds [60] (Fig. 3B). Like PLA2R, also
activate an IgG4 response in 3-5% of IMN patients. Unfortunately, so
far few studies have focused on the role of THSD7A in MN. THSD7A
participates in cell adhesion [61], being present in foot processes
near of slit diaphragms [62]. Binding of anti-THSD7A causes fibre
disorganization and cell dissociation and apoptosis [63]. Unlike pa­
tients with IMN associated with anti-PLA2R antibodies, MN associ­
ated with anti-THSD7A has been shown to have an increased risk of
developing tumors [64,65], specially of prostate, breast, renal and
colorectal, where THSD7A is over expressed [65].
- Other antigens: Recently, studies have appeared that describe new
antigens that could be involved in the development of MN. Lecithin-
cholesterol acetyltransferase (LCAT) is an enzyme involved in
cholesterol metabolism which has been found in immunocomplexes
with anti-LCAT antibodies on the walls of the glomerular capillaries
of MN patients [66]. On the other hand, proteomic studies have
allowed the detection in glomerular podocytes of antibodies against
antigens such as superoxide dismutase 2, aldose reductase and alpha
enolase, which are not present in cell surface of healthy glomerulus
[67,68].
PLA2R and THSD7A may represent about 85% of IMN. However, the
presence of false negatives has also been suggested when detecting an­
tibodies in the early stages of the disease [69]. In any case, the remaining
15% may be due to other antigens not yet described [70]. Possible
reasons why these new antigens have not been discovered were still
picked up by Beck. [70] (Table 2).
To finish, studies that jointly compare the presence and absence of
the different antigens against which antibody production has been
I. Nieto-Gañán et al. Clinical Immunology 237 (2022) 108976

Fig. 3. Structure of PLA2R and THSD7A. These receptors are two type I transmembrane glycoprotein. A) PLA2R: composed of a large extracellular portion which
consists of an N-terminal cysteine-rich region (CRD), a fibronectin-like type II domain (FNII), a tandem repeat of eight C-type lectin domains (CTLD), a trans­
membrane domain (TMD), and a short intracellular C-terminal domain (CD). In red are indicated typical variants associated with MN. The blue loop shows that in the
bent configuration, the-N terminal domain not binds with C-type lectin-like domains. B) THSD7A: composed of a large extracellular portion which consists of
thrombospondin type-1 repeats (TSRs), which tend to alternate between group 1 and group 2 TSRs, differing only in the positions of the three intradomain disulfide
bonds. GBM; Glomerular basement membrane.

Fig. 4. Anti-phospholipase A2 receptor antibodies and idiopathic membranous nephropathy in a peripheral capillary from a normal glomerulus. The basement
membrane separates endothelium from podocyte. A) Phospholipase A2 receptors (PLA2R) are localized on podocyte foot processes. B) In idiopathic membranous
nephropathy, autoantibodies bind to PLA2R. C) This activates complements with the formation of MAC and podocyte injury, with disociation of actin cytoskeleton.

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I. Nieto-Gañán et al.
Table 1
Functions of sPLA2-PLA2R binding (adapted from [50,55–58]).
Functions of sPLA2-PLA2R binding
Positive Negative
Activation of the mitogen-activated Endocytosis of sPLA2 protecting cells
protein kinase (MAPK) cascade. of enzymatic activities.
Production of lipid mediators Cell degradation
Release of arachidonic acid in bone
marrow-derived mast cells
ROS production
Activation of DNA-damage pathways
Table 2
Possible reasons why the remaining MN autoantigens have not been discovered
yet (adapted from [70]).
Rare antigens
Non-glomerular antigen derived from circulation from other tissue or environment.
Neo-antigen not expressed in normal kidney
Antigen that is difficult to extract from glomeruli
Humoral epitope not detectable with current available techniques
Non-IgG4 autoantibody that difficult detection
described in IMN patients are required to determine their usefulness in
monitoring the disease.
4.3. Risk allele variants for idiopathic MN
Some reports have suggested a genetic predisposition to IMN
[22,25,26,71,72], although is not a typical Mendelian hereditary dis­
ease. Related with this, IMN seem associated in Caucasoid with HLA-
B*08 HLA-DRB1*03 haplotype as well some HLA-DQA1 alleles and
other genes coded in HLA class II region of chromosome 6 as TAP and
HLA-DM [73–79]. Regards to HLA, recent genome-wide association
studies (GWAS) employed single-nucleotide polymorphisms (SNPs)
revealed high association of the 6p21 HLA-DQA1 and 2q24 PLA2R1 loci
in IMN patients, showing an additive effect when 4 risk alleles are
present increased the OR about 80-fold [3]. This association was
confirmed in European [80,81] and Asian populations [82,83].
Taking into account the linkage disequilibrium existing in the HLA
genes, HLA haplotypes DRB1*03:01 DRB3*02:02 DQA1*05:01
DQB1*02:01 [51,80,84,85], DRB1*15:01 DRB5*01:01 DQA1*01:02
DQB1*06:02[51,86–88] and MHC 8.1 (HLA-A*01 HLA-B*08 HLA-C*07)
[85] seem to confer risk of IMN.
Several hypotheses have been proposed to explain the role of HLA in
the development of the disease. First, it is possible a direct interaction
between antigen binding sites on HLA-DQA1 molecules and specific
PLA2R derived peptides. Second, mimicry between microorganisms or
other exogenous antigens and some variants of PLA2R could activate the
production of anti-PLA2R antibodies in patients with some HLA-DQA1
alleles which predispose to autoimmune diseases [89].
It has been suggested that variants that affect the coding and non-
coding regions of PLA2R1 could influence the degree of expression of
PLA2R as well as the conformation of binding epitopes with antibodies,
triggering autoimmune events [90]. However, only sequences in 5’
intronic regions have been related to MN [90], maybe by alteration in
the expression level or in transcription process.
Using predictive algorithms, sequences in CTLD1 and CTLD7 do­
mains of PLA2R receptor have showed high binding affinity with HLA
mollecules [87]. However, more sequence-based methods and cell and
molecular analyses are needed to understand how variants of PLA2R1
and HLA-DQA1 loci interact increasing predisposition to IMN.
Other genes have also been related with predisposition to IMN. The
tumor necrosis factor (TNF) allele G308A and the TNFd microsatellite
polymorphisms are strongly associated with occurrence and initiation of
MN by increased TNF production[91,92], whose levels have risen in the
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Clinical Immunology 237 (2022) 108976
serum and urine of patients with MN compared with other renal patients
[93,94].TNFα seems to be involved in dyscohesion at the podocytes’ slit
membrane with disorganization of actin filaments [95].
Nephrin (NPHS1) is a podocyte protein joining the slit diaphragm to
modulators of actin, maintaining glomerular permeability [96] (Huber
and Benzing, 2005). Several polymorphisms in NPHS1 loci have been
associated with susceptibility and remission to IMN [97].
Also there is a relation between the 4G allele of Plasminogen acti­
vator inhibitor type (PAI1) and renal deterioration and increased car­
diovascular problems in MN patients [98]. This allele is associated with
increased transcriptional activity and therefore with high PAI1 levels
[99].
Some polymorphisms in the IL-6 and STAT4 [100,101] and Toll-like
receptor 9 (TLR9) [102] genes appear to be related to increased prob­
ability of IMN.
All these data seem to indicate that a combination of several genetic
factors participate in the onset of the disease as well as in the control of
glomerular permeability and the processes of inflammation and fibrosis.
4.4. Exogenous antigen
BSA can contribute to the development of MN in about 2% of chil­
dren aged <5 years[103], since in some of these patients with IMN have
been found high serum titres of anti-BSA antibodies (IgG1 and IgG4).
Apparently, the BSA detected in children migrates in the basic pH region
while in adults it does in neutral pH ranges. Cationic BSA could be
formed by differences in food processing and intestinal microbiota
respect to the adult [104,105]. Cow’s milk is the major source of BSA in
young children. All this suggests that some IMNs can be caused by
exogenous food antigens, being fundamental their identification to
remove them from the diet instead of using immunosuppression in the
treatment of kidney diseases. This has been explained by a dysregulation
of the IL-13 route, leading to production of IgE specific antibodies of
food components[106]. It should be noted that BSA immunocomplexes
have only been detected in those MN patients without anti-PLA2R an­
tibodies [89].
Alloimmune reactions also can happen in enzyme replacement
therapy (ERT) [107–109], arising alloantibodies with or without clinical
relevance. A few cases of MN by ERT have been reported, although the
prevalence is probably underestimated. Two of these patients with
Pompe and mucopolysacaccharidosis type VI who were treated respec­
tively with recombinant human alpha-glucosidase (rhGAA) [110] and
recombinant arylsulfatase B (rhASB) [111], developing MN. In these
cases, given the need of patients to receive recombinant lysosomal en­
zymes, it is advisable to monitor their proteinuria to additionally pro­
vide immunosuppressive therapy when necessary and thus avoid a
relapse of kidney disease.
On the other hand, Hepatitis, Helicobacter pylori and tumor antigens
as well as thyroglobulin, and DNA-containing material have been found
in subepithelial deposits in patients with secondary MN [112–115].
Finally, a rare form of IMN is characterized by deposits of mono­
clonal IgG1 (rarely IgG3) in the outer layer of basement membranes
[116]. These immunoglobulines are not apparently directed against any
glomerular structure, although their precipitation in the subepithelial
space induces the development of MN [117].
Taking all this into account, it seems that in the future new antigens
may be found in MN patients.
4.5. Role of complement in MN
Complement activation is normally regulated to avoid autoimmune
events by several complement regulatory proteins (CRPs).
In podocytes, the surface-bound regulatory proteins CR1 (C3b re­
ceptor), membrane cofactor protein (MCP, CD46), and decay-
accelerating factor (DAF, CD55) act at C3 and C5 convertases level. In
addition, formation of membrane attack complex (MAC, C5b-9) is
I. Nieto-Gañán et al. Clinical Immunology 237 (2022) 108976

prevented by plasma clusterin and vitronectin and the podocyte-
expressed CD59. Their regulatory capacity can be overcome by the de­
posit of immunocomplex in the subepithelial area of podocytes
[118,119] or several polymorphisms of CRPs [120–122] (Fig. 5).
Unlike the secondary MN where the classic pathway of complement
plays an important role, IMN is characterized by IgG4 deposits which
not activate this pathway [123,124], being the lectin and alternative
pathways involved in the MAC formation. In fact, characteristics C1q
deposits of the classical pathway are generally not seen on immuno­
fluorescence of IMN patients. Further, mannan-binding lectin (MBL) has
been identified in the glomeruli of many patients with IMN [125], which
seems bind to anti PLA2R IgG4 antibodies because they lack galactose
[33].
However, there are exceptions. About 5% of PLA2R-associated IMN
patients lack antibodies of IgG4 subclass. Besides, neonatal alloimmune
MN is produced by maternal IgG1. [47,126].
Complement activation and MAC formation by immune complex
deposits participate in direct podocyte injury and proteinuria [99,101].
Presence of MAC in low concentration activates several mediators that
modify the metabolism of podocytes, the structure of the cytoskeleton,
the location of nephrine, the formation of extracellular matrix as well as
the integrity of DNA [32,127,128]. Also causes upregulation of NADPH
oxidoreductase with formation of reactive oxygen species which injury
several components of podocyte and glomerular basement membrane
components. Related with this, podocyte produce new extracellular
matrix that accumulate between immune deposits originating the
typical “spikes” observed by silver staining [89].
Simultaneously podocytes active mechanisms to limit the injury and
promote recovery of complement-dependent cytotoxicity [129–131].
One of these mechanisms is based on endocytosis of the MAC and its
subsequent elimination in the urine, being a biomarker of kidney dam­
age [132].
Besides, the accumulation of misfolded proteins in the endoplasmic
reticulum (ER) leads to ER stress [133,134]. Various studies suggest that
complement react against these proteins together with the ubiquitin-
proteasome system and autophagy [135–137]. However, continuous
ER stress is cytotoxic by activation of pro-apoptotic pathways [138].
5. Diagnostics
First assessment of a patient with a nephrotic syndrome suggestive of
MN must include detailed medical history and patient examination.
Analytical test should include serological markers of systemic autoim­
munity such as antinuclear antibodies, anti-dsDNA, anti-ribonucleo­
proteins, anti-Smith, antiRo(SSA), anti-La(SSB), anti-topoisomerase I
(Scl-70), anti-centromere, anti-Jo-1, anti-cardiolipin, anti-ß2-glycopro­
tein I antibodies, thyroid autoimmunity and complement values. These
are complementary tests that help diagnose primary membranous ne­
phropathy. [139,140].
Proteinuria and serum creatinine are considered the gold-standard
clinical biomarkers to risk-stratify MN patients. Moreover, urinary
markers of renal tubular damage, such as Beta2 microglobulin, N-acetyl-
β-D-glucosaminidase (NAG), retinol-binding protein (RBP), kidney
injury molecule 1 (KIM-1) and neutrophil gelatinase-associated lipocalin
(NGAL) have been also proposed to risk-stratify patients with MN.
However, the levels of these biomarkers seem to not correlate with the
severity of the disease [141].
Currently, the diagnosis of MN essentially relies on the clinical fea­
tures and pathological findings after renal biopsy. However, biopsy is an
invasive procedure with some disadvantages, such as risk of bleeding,
secondary infection and elevated cost [142]; nevertheless, staining of
renal tissue is more sensitive, since serum antibodies can become
negative spontaneously, or when patients are treated with immuno­
suppression. Moreover, findings from renal biopsies are helpful not only
for confirming the diagnosis of MN, but also allowing an estimation of
tissue damage, i.e. tubular atrophy and interstitial fibrosis or glomerular
sclerosis, as well as diagnosis of lesions not related to MN [140].
Nevertheless, antibody detection in serum of nephrotic patients has been
shown to be extremely specific for the diagnosis of MN; these serological
tests are now commercially available and is increasingly being

Fig. 5. Summary of complement activation and regulation in membranous nephropathy. Complement can be activated by classical, lectin, or alternative pathways.
While the classical pathway is activated in secondary forms, lectin and alternative pathways play an important role in primary MN. All three pathways converge to C5
convertase formation. Regulatory proteins (complement receptor-1 [CR1], decay accelerating factor [DAF], membrane cofactor protein [MCP]) control de formation
of C5 convertase. Cleavage of C5 produces the chemotactic factor C5a and C5b which combines with C6, C7, C8, and multiple C9 molecules to form the membrane
attack complex (MAC). C5b-9 formation is regulated by cell-bound CD59. Clusterin and vitronectin prevent insertion of MAC in the membrane

7
I. Nieto-Gañán et al.
implemented into clinical practice. The reported sensitivities and spec­
ificities are highly variable depending on the method used, patient
population studied, and cut-off levels that are used to define a positive
result [143].
5.1. Serological detection techniques
Anti-PLA2R was first identified in patient sera by performing western
blot (WB) using protein extracts from normal human glomeruli, which
were electrophoresed under non-reducing conditions (SDS-PAGE).
However, this method has limited use in clinical practice because it is
time-consuming and has a complex standardization[144,145]. In 2011,
a recombinant cell-based indirect immunofluorescence (IIF) assay for
detection of anti-PLA2R antibodies was developed [146]. Although this
assay is relatively inexpensive and easy to perform, it is not well suited
to high throughput laboratories and can be troubled by subjective
interpretation [147,148].
Years later, a group developed an in-house enzyme-linked immu­
nosorbent assay (ELISA) which included as solid-phase an extracellular
domain of PLA2R produced by recombinant techniques [149]. ELISA
may become a preferred method in many clinical laboratories because it
provides quantitative results, is not prone to subjective interpretation,
and is well-suited for high sample volumes [143].
Recently, a novel quantitative assay was reported. This is an
observer-independent immunoassay on an addressable laser bead
immunoassay (ALBIA) platform (Luminex technology) that employed
cell lysates bearing the full-length recombinant human protein to reli­
ably detect anti-PLA2R antibodies in the serum of IMN patients. This
immunoassay is capable of test multiple targets of other nephrotoxic
antibodies or immunological markers in a single assay and requires only
small serum sample volumes of 2–20 μL [147,148]. A comparison be­
tween the CBA-IFA, ELISA and ALBIA platforms, showed similar ca­
pacity across the different tests to detect anti-PLA2R autoantibodies
[148].
5.1.1. Anti PLA2R antibodies
PLA2R autoantibodies has proved to be a valuable biomarker for the
diagnosis of IMN, with a high specificity. However, it is important to
remember that they are also found in a very small proportion of sera
from patients with secondary MN. Anti-PLA2R antibodies are not only
useful for diagnosis; a positive test may be used in conjunction with
clinical features to indicate a need for immunosuppressive therapy and
the autoantibody titers used to monitor patients during therapy [148]. It
is useful because circulating anti-PLA2R antibodies reflect the immu­
nological activity of disease and have been shown to disappear before
clinical remission of nephrotic syndrome and to reappear in the circu­
lation before clinical relapse [147].
Anti-PLA2R antibodies prevalence can vary by geographical regions.
This antibodies are positive in approximately 70 to 80% of patients with
IMN in Europe[150], EEUU[11], and Asia, with the exception of Japan
where the prevalence of these antibodies is lower than in other Asian
countries (about 50% of patients with IMN) [151].
After a kidney transplantation, anti-PLA2R antibodies are excep­
tionally detected in “de novo” cases as compared with recurrent MN in
kidney transplant patients (8% versus 83%)[152]. Nearly 50% of cases
of recurrent MN on the kidney graft are associated with the presence of
anti-PLA2R antibodies before the trasplantation. The detection or
persistence of anti-PLA2R in kidney transplant patients has been asso­
ciated with an increased risk of loss of graft function [153].
5.1.2. THSD7A antibodies
In 2014, anti-thrombospondin type 1 domain-containing 7A
(THSD7A) was identified as a second autoantigen for another group of
MN patients. [4,10]. These antibodies were noted to be positive in 3%–
5% of patients with IMN who were anti-PLA2R negative, with higher
prevalence in women [4]. PLA2R and THSD7A use to be mutually
8
Clinical Immunology 237 (2022) 108976
exclusive, however, rare cases of dual positivity have been described
[154,155]. The detection of circulating autoantibodies have been
possible by western blot and IIF, which provide only semi-quantitative
titers. In 2019, a novel ELISA was reported as an useful tool in the
diagnosis of MN patients for THSD7A-associated disease, to carefully
monitor disease activity and response to treatment during follow-up,
and predict clinical outcome[154].
5.1.3. Other potentially pathogenic antibodies
Other proteins postulated that act as autoantigens in MN include
anti–manganese superoxide dismutase (SOD2), aldose reductase (AR),
cationic bovine serum albumin and alpha-enolase in cases of childhood
MN [103]. Anti-alpha-enolase antibodies have been known to be present
in the serum of patients with primary and secondary MN (nearly 70%)
but they are not detected within the subepithelial deposits [156,157].
Antibodies directed against SOD2 and AR, have also been detected in the
serum and tissue of glomeruli in biopsy samples from patients with MN
[67]. These cytoplasmic antigens are not usually accessible to circu­
lating antibodies under normal conditions. However, when oxidative
stress occurs, they can migrate to the cell membrane and serve as targets
for circulating antibodies. The activation of complement leading could
be a cause of oxidative stress in podocytes [158]. The initial lesions
induced by the immune complexes involving PLA2R may induce
oxidative stress responsible for the novo membrane expression of pro­
teins, which are physiologically cytoplasmic, leading to the formation of
new autoantibodies. Their pathogenic role in the initiation and/or
maintenance of the disease is still hypothetical [12].
5.2. Histological features of MN
Renal biopsy is still the gold standard for the diagnosis of MN. A
granular positivity for IgG along the glomerular basement membrane
and electrondense deposits restricted to the subepithelial space of the
glomerular filtration barrier are the characteristic morphologic features.
The diagnosis of PLA2R-associated MN can be made by staining for the
PLA2R antigen in the renal tissue [7,140,155,159] (Fig. 1).
Tissue testing for PLA2R antigen can been performed by immuno­
histochemistry (IHC) on paraffin-embedded tissue, IIF on paraffin-
embedded tissue and IIF on frozen[11,140,160]. Subepithelial deposits
in secondary forms of MN are almost always PLA2R-negative.[143,161].
Generally, a strong association between glomerular PLA2R staining and
circulating anti-PLA2R antibodies is found [150], particularly when
autoantibody levels are measured at the same time of the biopsy
assessment. However, glomerular PLA2R staining is not considered a
diagnostic test for active disease, since the positivity of glomerular
PLA2R staining with undetectable circulating anti-PLA2R autoanti­
bodies is unlikely and may reflect an immunologically inactive disease
as a positive PLA2R antigen can persist for weeks or months after
remission [141,162].
IgG subclass analysis in the tissue indicates that IgG subclass patterns
may give some information about pathogenesis and prognosis. [11,163].
Immunohistological studies have shown that IgG4 is the predominant
IgG subclass in the glomerular immune deposits in IMN, leading to the
assumption that IgG4 antibodies may induce disease. In contrast, the
absence of IgG4 and the presence of IgG1 and IgG2 in renal biopsies are
considered to be characteristic for secondary, malignancy-associated
MN [164,165].
6. Treatment
MN have been described as a large spectrum of disease severity and
shows cases of spontaneous remission without therapy, being difficult to
predict its progression is, which explains the therapeutic uncertainties
that still persist today. In less than 30% of the cases, the disease pro­
gresses slowly towards severe renal insufficiency despite optimal sup­
portive care combined with classical immunosuppressive therapy
I. Nieto-Gañán et al.
[147,166–168].
Today it is accepted that the type of treatment must be adapted to the
the risk of progressive loss of kidney function of each patient, based in
clinical and laboratory data (GFR (glomerular filtration rate; protein­
uria, response to renin-angiotensin-aldosterone system inhibitors
(ACEi), serum albumin, anti-PLA2R antibodies levels, etc.) and can be
summarized into 4 categories: low, moderate, highy and very high risk
[169]. A brief outline of the different treatment guidelines is shown in
Fig. 6.
General considerations for treating patients with primary MN
include that forms with the possibility of spontaneous remission (non
nephrotic proteinuria (<3.0 g/day), high serum creatinine level or un­
controlled arterial hypertension [170]) should receive supportive
treatment, consisting of renoprotective treatment as drugs that inhibit
the renin-angiotensin-aldosterone system (ACEs), control of arterial
hypertension, dyslipidaemia, excess weight, and other cardiovascular
risk factors [169] in appropriate doses to maintain a Blood Pressure
<130/80 mmHg and exert a sustained antiproteinuric effect. As re­
flected in various studies [171,172] these patients have a good evolution
without immunosuppression. Induction of partial remission (proteinuria
less than 3.5 g/24h) is associated with significantly higher renal survival
than non-remission [173]. Therefore, although the optimal goal would
be to achieve a complete remission, obtaining a partial remission can be
considered acceptable.
In accordance with the KDIGO guidelines [169], Immunosuppressive
therapy should be restricted to patients considered at risk for progressive
kidney injury, cases that maintain nephrotic proteinuria after an
observation period of at least 6 months and provided that proteinuria
does not tend to decrease. Patients with advanced chronic renal failure
(glomerular filtration rate <30 ml/min/1.73m2) should not follow
immunosuppressive treatment either, given the limited benefit it can
provide in these cases. Patients should follow a diet without salt and
with diuretics to reduce edema and allow a normal life. Treatment with
ACE inhibitors, in addition to treating hypertension, reduces protein­
uria, facilitating possible spontaneous remission. Regarding anticoagu­
lant treatments, the KDIGO guidelines recommend their use in patients
Fig. 6. Risk-based treatment of Membranous Nephrophathy according to KDIGO 2021 guideline (adapted from [169] (RTX: Rituximab; CNI: Calcineurin inhibitor).
9
Clinical Immunology 237 (2022) 108976
who present thrombotic risk factors such as obesity, genetic predispo­
sition, heart failure, and Prophylactic anticoagulant therapy should be
based on an estimate of the risk of thrombotic events and the risk of
bleeding complications [169].
On the other hand, forms that persist over time with nephrotic syn­
drome without deterioration of renal function will require immuno­
suppressive therapy, being predictive factors of progression to the end-
stage kidney disease (ESKD) a nephrotic persistent proteinuria for more
than 6 months, a decrease in glomerular filtration rate at the time of
diagnosis, uncontrolled arterial hypertension and the presence of
interstitial fibrosis and tubular atrophy seen on a renal biopsy
[147,169,174,175].
Severe forms with progressive deterioration of kidney function, in­
cludes patients with a progressive deterioration of renal function (in­
crease in creatinine> 30% of the baseline value during the first 6-12
months of evolution), complications caused by nephrotic syndrome (i.e.
pulmonary thromboembolism) or with extreme hypoalbuminemia (less
1.5-2 g/dl) and persistent massive edema that does not respond to
combinations of diuretics. In these patients, the use of anticalcineurinics
is not recommended due to their nephrotoxicity. Furthermore, there are
hardly any studies on the efficacy of treatment with RTX and MMF,
among others. Therefore, the most widely used therapeutic option is the
Ponticelli scheme[166,176]. In fact, in a study comparing the efficacy of
the Ponticelli scheme, cyclosporine, and supportive treatment, the first
group showed statistically significantly better results [177].
Below is a brief description of the main immunosuppressive treat­
ments used:
Corticosteroids plus alkylating agents (cyclophosphamide or chlor­
ambucil): The combination of corticosteroids and cyclophosphamide or
chlorambucil, administered alternatively for 6 months, starting with
corticosteroids, constitutes the Ponticelli scheme. The rate of complete
or partial remissions reaches 70-80% of cases [168,178], although side
effects can be serious, especially when chlorambucil is used. That is why
cyclophosphamide is currently used as an alkylating agent. Some au­
thors prefer the simultaneous use of both treatments [166,176],
although it is unknown which regimen is more effective. What is known
I. Nieto-Gañán et al.
is that the exclusive use of corticosteroids is not effective[179].
Calcineurin inhibitor (CNI or anticalcineurinics): The use of cyclo­
sporine[180] and tacrolimus [181–186] has been shown effective in
MN, inducing complete or partial remission in more than 70-80% of
cases. Usually, the initial dose of cyclosporine is 3.5-5.0 mg/kg/d,
accompanied by steroids, while that of tacrolimus is 0.05-0.075 mg/kg/
d without steroids [180]. The doses of both drugs are adjusted according
to the blood levels. The recommended duration of treatment with
anticalcineurinics is 12-18 months with gradual withdrawal. In addition
to their immunosuppressive effect, they also have a direct anti­
proteinuric effect on the podocyte thanks to the interaction with syn­
aptopodin [187]. The main problem generated in the treatment of MN
with anticalcineurinics is the high rate of relapse (close to 50%) after
withdrawal of the drug, which is usually associated with high protein­
uria. Some studies have shown that the administration of rituximab
before starting tacrolimus withdrawal can reduce the number of relapses
[188]. Studies are underway to evaluate the efficacy of this sequential
therapy with tacrolimus-rituximab. The response to anticalcineurinics is
more effective with lower proteinuria and better renal function at the
beginning of treatment.
Rituximab: There are case series studies in which the use of rituximab
(RTX) induces complete or partial remission of the nephrotic syndrome
in 50% -60% of cases [189–191] with good tolerance. There is no
consensus on the optimal regimen of RTX to treat MN. The doses used
vary between 375 mg/m2/week for four consecutive weeks or 1 or 2
doses of 1 g [192]. Anti-PLA2R1 antibodies levels are useful for the
evaluation of rituximab efficacy. No correlation has been seen between
the degree of CD20+ lymphocyte depletion and the occurrence of re­
missions or relapses [193,194]. In a study called GENRITUX [190], no
short-term differences were observed between treatment with rituximab
plus supportive treatment and only conservative treatment. However, in
the long term, the group treated with rituximab presented a greater
increase in serum albumin, a more marked decrease in the anti-PLA2R
titer, and a greater degree of remission. This has been seen in other
studies as well[44,153,195]. Therefore, it appears that the use of rit­
uximab in patients with MN is slow to take effect. A new protocol based
on the association of RTX and cyclosporine for 6 months, followed by a
second cycle of RTX and tapering of cyclosporine during 18 months as a
maintenance phase, demonstrated that proteinuria decreased by 80% at
6 months, although complete remission only was observed in 54% of
patients at 12 months [196]. Some studies suggest that rituximab may
be an effective option in patients with recurrence of MN or MN de novo
after kidney transplant [197]. Although it is safe, several cases of acute
non ischemic cardiomyopathy [198] and progressive urticarial derma­
titis [199] related to the RTX administration have been described.
Mycophenolate (MMF): Existing studies with this drug show con­
flicting results. Thus, there are studies that demonstrate its efficacy
[200] and others in which no differences are observed with patients with
supportive treatment [201]. MMF significantly reduced proteinuria but
had no significant effect on the induction of complete remission and was
also associated with an increased risk of relapse[176,202]. MMF may be
beneficial when associated with steroids [169]. Other studies suggest
that the use of MMF may be useful in patients with resistance to other
therapies although further studies are needed to confirm this [203].
Adrenocorticotropic hormone (ACTH): Subcutaneous administration
of synthetic ACTH has shown some efficacy in patients with MN and
nephrotic syndrome in several case series [204,205]. Their long-term
efficacies as well as its side effects are unknown.
Proteasome inhibitor: A novel therapy based on proteasome inhibitor
(bortezomib, 4 doses of 1.3 mg/m over 2 weeks) efficiently reduced
proteinuria in a case of recurrent MN after renal transplantation that had
been only partially responsive to RTX [206]. In addition to rituximab,
the development of new monoclonal antibodies targeting B cells such as
ofatumumab and belimumab as well as new treatments such as borte­
zomib and eculizumab provides a variety of useful therapies with the
potential to replace the nonspecific and toxic immunosuppressants used
10
Clinical Immunology 237 (2022) 108976
actually in the treatment of MN [207]. In the future, treatment protocols
for MN patients will probably be individualized based on the level of
anti-PLA2R1 antibodies and proteinuria [208].
7. Conclusions and future directions
The description of the autoimmune nature of multiple cases of IMN
has meant an important change in the therapeutic approach, diagnosis
and monitoring of this pathology. In this respect, the discovery of new
autoantibodies and their epitopes could well pave the way for a better
understanding of the immunopathogenesis of IMN. Therapies based on
protreosome inhibitors and the use of new monoclonal antibodies tar­
geting B cells may likewise have a place in future treatment.
Funding
“This research received no external funding”
Ethical approval
Not required.
Declaration of competing interest
“The authors declare no conflict of interest.”
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