SlideShare a Scribd company logo
1 of 80
Membranous Nephropathy
(4 Parts)
Mohammed Abdel Gawad
Nephrologist – Alexandria - Egypt
Founder & Chairman of NephroTube
drgawad@gmail.com
To download the lecture with full
animations contact me
drgawad@gmail.com
For more Nephrology lectures visit
www.NephroTube.com
Membranous Nephropathy
Part 1
Presentation & Pathogenesis
Mohammed Abdel Gawad
Nephrologist – Alexandria - Egypt
Founder & Chairman of NephroTube
drgawad@gmail.com
Membranous Nephropathy
• Glomerular disease:
–Nephrotic syndrome in 60% to 70%
–Normal or mildly elevated blood pressure at
presentation
–Urine:
• Benign urinary sediment
• Nonselective proteinuria
Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
Membranous Nephropathy
• Subepithelial Immune deposits of IgG and
complement
Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
Membranous Nephropathy
• Etiology:
Primary
(two third of cases)
Secondary
Kidney Int Suppl. 2012;2:139-274
Membranous Nephropathy
• Etiology:
Secondary
Kidney Int Suppl. 2012;2:139-274
Membranous Nephropathy
• Etiology:
Secondary
Kidney Int Suppl. 2012;2:139-274
Membranous Nephropathy
• Etiology:
Secondary
Kidney Int Suppl. 2012;2:139-274
My Starting Point
A biopsy proven diagnosis of
Membranous Nephropathy (MN)
Talk Outline
Steps of Management of MN
(Diagnosis & Treatment)
Evaluation
of secondary causes
Therapy:
Secondary: Treat the cause
Idiopathic: Specific
Treatment
To go through evaluation of secondary causes
we have to discuss first Clinically applied
Pathophysiology of MN
Kidney Int Suppl. 2012;2:139-274
Subepithelial deposits MN
Possible Mechanisms
Glassock RJ. N Engl J Med 2009;361:81-83.
Possible Mechanisms of the Formation of Subepithelial Deposits in Experimental Models of, and Patients with,
Membranous Nephropathy.
1ry MN2ry MN 2ry MN
Subepithelial deposits MN
Possible Mechanisms
Glassock RJ. N Engl J Med 2009;361:81-83.
Possible Mechanisms of the Formation of Subepithelial Deposits in Experimental Models of, and Patients with,
Membranous Nephropathy.
1ry MN2ry MN 2ry MN
Animal Model - Heymann nephritis
Megalin
Quigg RJ. Kidney Int 2003; 64:2318.
Congenital MN have been shown to be mediated by an antibody to neutral endopeptidase
(NEP), an antigen expressed on the podocyte membrane. In these cases, mothers with a
hereditary absence of NEP become sensitized during pregnancy and passively transfer anti-NEP
IgG to the infant, who is born with congenital nephrotic syndrome caused by MN through an
alloimmune mechanism
Human Podocyte Antigens
Neutral Endopeptidase
Human Podocyte Antigens
Phospholipase A2 Receptor
Human Podocyte Antigens
Thrombospondin type - 1 domain -
containing 7A (THSD7A)
• A transmembrane protein expressed on podocytes.
• Responsible Ab in 10% of primary MN with negative
anti-PLA2R Ab.
Gödel M et al. N Engl J Med 2015; 372:1073.
Iwakura T et al. PLoS One 2015; 10:e0138841.
Mechanism of primary MN
Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
Mechanism of primary MN
Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
Qu Z et al. Nephrol Dial Transplant 27: 1931–1937, 2012
Mechanism of primary MN
Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
Characteristics of Primary MN
Pathogenesis
• Anti PLAR2 Ab.
• Th2 Humoral immunity.
• IgG4 subclass.
• C5b9 (MAC)
Characteristics of Primary MN
Pathogenesis
• Anti PLAR2 Ab.
• Th2 Humoral immunity.
• IgG4 subclass.
• C5b9 (MAC)
Serum PLA2R auto antibodies test is a
good +ve but not good -ve marker for
MN.
Anti-PLA2R Titers Clinical Significance
(1)
Anti-PLA2R Titers Clinical Significance
(2)
• anti-PLA2R titers strongly correlated with
clinical status
• lower anti-PLA2R titers were associated with a
higher rate of spontaneous remission
• a decline in anti-PLA2R predicted the clinical
response to immunosuppressive therapy
Hofstra JM et al. Clin J Am Soc Nephrol 2011; 6:1286.
Hofstra JM et al. J Am Soc Nephrol 2012; 23:1735.
Ruggenenti P et al. J Am Soc Nephrol 2015; 26:2545.
Anti-PLA2R
Is it only related to Idiopathic MN?
J Am Soc Nephrol 22: 1137–1143, 2011.
Anti-PLA2R Titers Clinical Significance
(3)
• Highly suggestive of primary MN
• But does not exclude the coexistence of:
–hepatitis virus infection,
–malignancy,
–another associated rheumatologic or
inflammatory disease.
J Am Soc Nephrol 22: 1137–1143, 2011.
www.NephroTube.com
Membranous Nephropathy
(Part 2)
Diagnosis (Primary vs Secondary)
Mohammed Abdel Gawad
Nephrologist – Alexandria - Egypt
Founder & Chairman of NephroTube
drgawad@gmail.com
Talk Outline
Steps of Management of MN
(Diagnosis & Treatment)
Evaluation
of secondary causes
Therapy:
Secondary: Treat the cause
Idiopathic: Specific
Treatment
Kidney Int Suppl. 2012;2:139-274
1- Biopsy
1ry MN
Subepithelial
IgG subclass 4
Anti PLA2R
2ry MN
- Ig other than IgG (e.g. IgA, IgM),
particularly in mesangium,
subendothelial, tubular BM
deposits.
- C1q deposits
- tubuloreticular structures in the
glomerular endothelial cells
Serum anti PL
3- Age
4th to 5th decade
(suggesting 1ry pathology, but not
excluding 2ry causes)
- ANA - Anti dsDNA
- HBsAg - HCV Ab
- Cryoglobulins - RF
- C3 - C4
- ESR - CRP
If not 4th to 5th decade
(suggesting 2ry pathology, but not
excluding 1ry causes)
Tumor screening:
When to screen ?
How to screen?
Laurence H Beck, Richard J Glassock. UpTodate. Oct 21, 2015.
Serum anti PL
3- Age
4th to 5th decade
(suggesting 1ry pathology, but not
excluding 2ry causes)
- ANA - Anti dsDNA
- HBsAg - HCV Ab
- Cryoglobulins - RF
- C3 - C4
- ESR - CRP
If not 4th to 5th decade
(suggesting 2ry pathology, but not
excluding 1ry causes)
Tumor screening:
When to screen ?
How to screen?
Laurence H Beck, Richard J Glassock. UpTodate. Oct 21, 2015.
Serum complement
is usually normal in
idiopathic MN
Serum anti PL
3- Age
4th to 5th decade
(suggesting 1ry pathology, but not
excluding 2ry causes)
- ANA - Anti dsDNA
- HBsAg - HCV Ab
- Cryoglobulins - RF
- C3 - C4
- ESR - CRP
If not 4th to 5th decade
(suggesting 2ry pathology, but not
excluding 1ry causes)
Tumor screening:
When to screen ?
How to screen?
Take care of what is called
PURE MEMBERANOUS
LUPUS NEPHROPATHY
where no clinical or
serological evidence of SLE.
Laurence H Beck, Richard J Glassock. UpTodate. Oct 21, 2015.
Malignancy Screening
When to screen?
If the anti-PLA2R antibody test is negative
+ the kidney histology is consistent with secondary MN
+ there is no other clear cause of secondary MN
+ risk factors or alarm signs:
• extensive smoking history,
• guaiac-positive stools,
• unexplained anemia or weight loss
Laurence H Beck, Richard J Glassock. UpTodate. Oct 21, 2015.
Malignancy Screening
How to screen?
Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
Malignancy Screening
How to screen?
Examination:
- LN.
- Systemic exam for any mass.
- CXR
- USS Abd & Pelvis
- CBC
- Occult blood in stool
Male > 50 = PSA Female > 50 = Mammogram
Body CT Scan (± other imaging) if cause is
not evident
Malignancy Screening
Frequency of screening
Cancer screening should continue for a period of
five to ten years after the diagnosis of MN
(since cancers associated with MN are typically diagnosed within
this time frame.)
Laurence H Beck, Richard J Glassock. UpTodate. Oct 21, 2015.
Membranous Nephropathy
(Lecture 4)
Management – Practical Approach
Mohammed Abdel Gawad
Nephrologist - Alexandria - Egypt
Founder & Chairman of NephroTube
drgawad@gmail.com
Talk Outline
Steps of Management
(Diagnosis & Treatment)
Evaluation
of secondary causes
Therapy:
Secondary: Treat the cause
Idiopathic: Specific
Treatment
Kidney Int Suppl. 2012;2:139-274
Spontaneous complete
remission of proteinuria
5 to 30 % at five years
Spontaneous partial remission 25 to 40 % at five years
End-stage renal disease in
untreated patients
14 % at five years,
35 % at 10 years,
41 % at 15 years
Possibility of Remission
Jha V et al. J Am Soc Nephrol 2007; 18:1899.
MN - Risk Categories
Low Risk Medium Risk High Risk
Serum
creatinine
and creatinine
clearance
Normal Normal or
near-normal
Deteriorating
renal function
Proteinuria <4 g/day 4-8 g/day >8 g/day
Supportive
treatment
period
over 6 months
of supportive
care
over 6 months
of supportive
care
over 3-6
months
of supportive
care
Fernando C. Clin J Am Soc Nephrol 3: 905-919, 2008
IMN – Treatment Algorithm
Kidney Int Suppl. 2012;2:139-274
Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
IMN – Treatment Algorithm
Kidney Int Suppl. 2012;2:139-274
Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
IMN – Treatment Algorithm
Kidney Int Suppl. 2012;2:139-274
Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
IMN – Treatment Algorithm
Kidney Int Suppl. 2012;2:139-274
Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
IMN – Treatment Algorithm
Kidney Int Suppl. 2012;2:139-274
Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
IMN – Treatment Algorithm
Kidney Int Suppl. 2012;2:139-274
Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
l
IMN – Treatment Algorithm
Kidney Int Suppl. 2012;2:139-274
Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
J Am Soc Nephrol. 2016 Oct 24
low =14–86 U/ml;
moderate =87–204 U/ml;
high ≥204 U/ml.
J Am Soc Nephrol. 2016 Oct 24
Repeat Kidney Biopsy
Kidney Int Suppl. 2012;2:139-274
Membranous Nephropathy
(Part 4)
Management – Practical Approach
(Rituximab)
Mohammed Abdel Gawad
Nephrologist - Alexandria - Egypt
Founder & Chairman of NephroTube
drgawad@gmail.com
IMN – Treatment Algorithm
Kidney Int Suppl. 2012;2:139-274
Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
IMN – Treatment Algorithm
Kidney Int Suppl. 2012;2:139-274
Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
Research
recommendations
2017 Jan;28(1):348-358
(GEMRITUX Study Group)
2017 Jan;28(1):348-358
(GEMRITUX Study Group)
2017 Jan;28(1):348-358
(GEMRITUX Study Group)
2017 Jan;28(1):348-358
(GEMRITUX Study Group)
2017 Sep;28(9):2729-2737
4 weekly doses
of 375 mg/m2
RTX infused
intravenously
2017 Sep;28(9):2729-2737
The dashed lines describe the events in RTX-treated patients
4 weekly doses
of 375 mg/m2
RTX infused
intravenously
N Engl J Med 2019;381:36-46.
130 patients who had membranous nephropathy
N Engl J Med 2019;381:36-46.
130 patients who had membranous nephropathy
N Engl J Med 2019;381:36-46.
N Engl J Med 2019;381:36-46.
N Engl J Med 2019;381:36-46.
N Engl J Med 2019;381:36-46.
N Engl J Med 2019;381:36-46.
IMN – Treatment Algorithm
Kidney Int Suppl. 2012;2:139-274
Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
Alternative: Rituximab
Membranous Nephropathy - Dr. Gawad

More Related Content

What's hot

Membranoproliferative glomerulonephritis s
Membranoproliferative glomerulonephritis sMembranoproliferative glomerulonephritis s
Membranoproliferative glomerulonephritis s
Mohammad Manzoor
 

What's hot (20)

Infection-related Glomerulonephritis (KDIGO 2021 Guidelines) - Dr. Gawad
Infection-related Glomerulonephritis  (KDIGO 2021 Guidelines) - Dr. GawadInfection-related Glomerulonephritis  (KDIGO 2021 Guidelines) - Dr. Gawad
Infection-related Glomerulonephritis (KDIGO 2021 Guidelines) - Dr. Gawad
 
IgA nephropathy
IgA nephropathyIgA nephropathy
IgA nephropathy
 
ANCA vasculitis (KDIGO 2021 Guidelines) - Dr. Gawad
ANCA vasculitis (KDIGO 2021 Guidelines) - Dr. GawadANCA vasculitis (KDIGO 2021 Guidelines) - Dr. Gawad
ANCA vasculitis (KDIGO 2021 Guidelines) - Dr. Gawad
 
Membranous Nephropathy
Membranous NephropathyMembranous Nephropathy
Membranous Nephropathy
 
Hypokalemia (Practical Approach) - Dr. Gawad
Hypokalemia (Practical Approach) - Dr. GawadHypokalemia (Practical Approach) - Dr. Gawad
Hypokalemia (Practical Approach) - Dr. Gawad
 
Membranoproliferative glomerulonephritis s
Membranoproliferative glomerulonephritis sMembranoproliferative glomerulonephritis s
Membranoproliferative glomerulonephritis s
 
Infection Related Glomerulopathy - Introduction – Rapid Overview - Dr. Gawad
Infection Related Glomerulopathy - Introduction – Rapid Overview - Dr. GawadInfection Related Glomerulopathy - Introduction – Rapid Overview - Dr. Gawad
Infection Related Glomerulopathy - Introduction – Rapid Overview - Dr. Gawad
 
Non EPO Management of Renal Anemia - Different Lines & Available Evidence - D...
Non EPO Management of Renal Anemia - Different Lines & Available Evidence - D...Non EPO Management of Renal Anemia - Different Lines & Available Evidence - D...
Non EPO Management of Renal Anemia - Different Lines & Available Evidence - D...
 
Rituximab in Nephrology (Different Uses & Available Evidence) - Dr. Gawad
Rituximab in Nephrology (Different Uses & Available Evidence) - Dr. GawadRituximab in Nephrology (Different Uses & Available Evidence) - Dr. Gawad
Rituximab in Nephrology (Different Uses & Available Evidence) - Dr. Gawad
 
Hypercalcemia (Practical Approach) - Dr. Gawad
Hypercalcemia (Practical Approach) - Dr. GawadHypercalcemia (Practical Approach) - Dr. Gawad
Hypercalcemia (Practical Approach) - Dr. Gawad
 
Lupus Nephritis (KDIGO 2021 Guidelines) - Dr. Gawad
Lupus Nephritis (KDIGO 2021 Guidelines) - Dr. GawadLupus Nephritis (KDIGO 2021 Guidelines) - Dr. Gawad
Lupus Nephritis (KDIGO 2021 Guidelines) - Dr. Gawad
 
The evaluation of monoclonal gammopathy
The evaluation of monoclonal gammopathyThe evaluation of monoclonal gammopathy
The evaluation of monoclonal gammopathy
 
IgA NEPHROPATHY (CLOSING THE LOOP) - Dr. Gawad
IgA NEPHROPATHY (CLOSING THE LOOP)  - Dr. GawadIgA NEPHROPATHY (CLOSING THE LOOP)  - Dr. Gawad
IgA NEPHROPATHY (CLOSING THE LOOP) - Dr. Gawad
 
Adult Minimal Change Disease (KDIGO 2021 Guidelines)
Adult Minimal Change Disease (KDIGO 2021 Guidelines)Adult Minimal Change Disease (KDIGO 2021 Guidelines)
Adult Minimal Change Disease (KDIGO 2021 Guidelines)
 
IgA Nephropathy (KDIGO 2021 Guidelines) - Dr. Gawad
IgA Nephropathy (KDIGO 2021 Guidelines) - Dr. GawadIgA Nephropathy (KDIGO 2021 Guidelines) - Dr. Gawad
IgA Nephropathy (KDIGO 2021 Guidelines) - Dr. Gawad
 
Updates in management of membranous nephropathy - Dr. Mohammed Kamal Nassar
Updates in management of membranous nephropathy - Dr. Mohammed Kamal NassarUpdates in management of membranous nephropathy - Dr. Mohammed Kamal Nassar
Updates in management of membranous nephropathy - Dr. Mohammed Kamal Nassar
 
Lupus Nephritis Guideline Review 2022
Lupus Nephritis Guideline Review 2022Lupus Nephritis Guideline Review 2022
Lupus Nephritis Guideline Review 2022
 
Diabetic nephropathy
Diabetic nephropathyDiabetic nephropathy
Diabetic nephropathy
 
AKI in Sepsis - Dr. Gawad
AKI in Sepsis - Dr. GawadAKI in Sepsis - Dr. Gawad
AKI in Sepsis - Dr. Gawad
 
KDIGO Lupus Nephritis
KDIGO Lupus NephritisKDIGO Lupus Nephritis
KDIGO Lupus Nephritis
 

Similar to Membranous Nephropathy - Dr. Gawad

Vetrugno, Exp Op Orph Drugs, 15
Vetrugno, Exp Op Orph Drugs, 15Vetrugno, Exp Op Orph Drugs, 15
Vetrugno, Exp Op Orph Drugs, 15
Vito Vetrugno
 
Focal Segmental Glomerulosclerosis (FSGS)
Focal Segmental Glomerulosclerosis (FSGS)Focal Segmental Glomerulosclerosis (FSGS)
Focal Segmental Glomerulosclerosis (FSGS)
Tauhid Bhuiyan
 

Similar to Membranous Nephropathy - Dr. Gawad (20)

Pneumonia Vaccination
Pneumonia VaccinationPneumonia Vaccination
Pneumonia Vaccination
 
Post infectious glomerulonephritis, PIGN
Post infectious glomerulonephritis, PIGNPost infectious glomerulonephritis, PIGN
Post infectious glomerulonephritis, PIGN
 
Serum interleukin - 6 level among sudanese patients with chronic kidney disea...
Serum interleukin - 6 level among sudanese patients with chronic kidney disea...Serum interleukin - 6 level among sudanese patients with chronic kidney disea...
Serum interleukin - 6 level among sudanese patients with chronic kidney disea...
 
Anti-Phospholipase A2 Receptor Antibody - Clinical Application for Membranous...
Anti-Phospholipase A2 Receptor Antibody - Clinical Application for Membranous...Anti-Phospholipase A2 Receptor Antibody - Clinical Application for Membranous...
Anti-Phospholipase A2 Receptor Antibody - Clinical Application for Membranous...
 
Kidney Disease In patients living with HIV
Kidney Disease In patients living with HIVKidney Disease In patients living with HIV
Kidney Disease In patients living with HIV
 
Sipuleucel_T Immunotherapy for Metastatic Prostate Cancer after Failing Hormo...
Sipuleucel_T Immunotherapy for Metastatic Prostate Cancer after Failing Hormo...Sipuleucel_T Immunotherapy for Metastatic Prostate Cancer after Failing Hormo...
Sipuleucel_T Immunotherapy for Metastatic Prostate Cancer after Failing Hormo...
 
Vetrugno, Exp Op Orph Drugs, 15
Vetrugno, Exp Op Orph Drugs, 15Vetrugno, Exp Op Orph Drugs, 15
Vetrugno, Exp Op Orph Drugs, 15
 
CKD and Genetics 2015
CKD and Genetics 2015CKD and Genetics 2015
CKD and Genetics 2015
 
Vaccination in CKD Patients
Vaccination in CKD PatientsVaccination in CKD Patients
Vaccination in CKD Patients
 
Focal Segmental Glomerulosclerosis (FSGS)
Focal Segmental Glomerulosclerosis (FSGS)Focal Segmental Glomerulosclerosis (FSGS)
Focal Segmental Glomerulosclerosis (FSGS)
 
Lupus Nephritis
Lupus NephritisLupus Nephritis
Lupus Nephritis
 
Cryptococcal Peritonitis in a Patient with Liver Cirrhosis: Case Report
Cryptococcal Peritonitis in a Patient with Liver Cirrhosis: Case ReportCryptococcal Peritonitis in a Patient with Liver Cirrhosis: Case Report
Cryptococcal Peritonitis in a Patient with Liver Cirrhosis: Case Report
 
Creutzfeld-Jakob Disease: Diagnosis and Management of Prion Diseases
Creutzfeld-Jakob Disease: Diagnosis and Management of Prion DiseasesCreutzfeld-Jakob Disease: Diagnosis and Management of Prion Diseases
Creutzfeld-Jakob Disease: Diagnosis and Management of Prion Diseases
 
HIVAN (Nefropatía asociada al VIH) Evidencia al 2015
HIVAN (Nefropatía asociada al VIH)  Evidencia al 2015 HIVAN (Nefropatía asociada al VIH)  Evidencia al 2015
HIVAN (Nefropatía asociada al VIH) Evidencia al 2015
 
ND-CKD Causes 21st July 2021.pptx
ND-CKD Causes 21st July 2021.pptxND-CKD Causes 21st July 2021.pptx
ND-CKD Causes 21st July 2021.pptx
 
Lupus Nephritis - 2021.pptx
Lupus Nephritis - 2021.pptxLupus Nephritis - 2021.pptx
Lupus Nephritis - 2021.pptx
 
Nefropatia de celulas falciformes
Nefropatia de celulas falciformesNefropatia de celulas falciformes
Nefropatia de celulas falciformes
 
Prions in the Urine of Patients with Variant Creutzfeldt–Jakob Disease
Prions in the Urine of Patients with Variant Creutzfeldt–Jakob DiseasePrions in the Urine of Patients with Variant Creutzfeldt–Jakob Disease
Prions in the Urine of Patients with Variant Creutzfeldt–Jakob Disease
 
A Study Of Clinical And Laboratory Profile Of Dengue Fever In A
A Study Of Clinical And Laboratory Profile Of Dengue Fever In AA Study Of Clinical And Laboratory Profile Of Dengue Fever In A
A Study Of Clinical And Laboratory Profile Of Dengue Fever In A
 
Csf ada hiv tbm
Csf ada hiv tbmCsf ada hiv tbm
Csf ada hiv tbm
 

More from NephroTube - Dr.Gawad

More from NephroTube - Dr.Gawad (20)

Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.GawadHemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
 
Vitamin D in Chronic Kidney Disease Which type, Which dose, Which patient? - ...
Vitamin D in Chronic Kidney Disease Which type, Which dose, Which patient? - ...Vitamin D in Chronic Kidney Disease Which type, Which dose, Which patient? - ...
Vitamin D in Chronic Kidney Disease Which type, Which dose, Which patient? - ...
 
Urinary Tract Infection (Clinical Tips) - Dr. Gawad
Urinary Tract Infection (Clinical Tips) - Dr. GawadUrinary Tract Infection (Clinical Tips) - Dr. Gawad
Urinary Tract Infection (Clinical Tips) - Dr. Gawad
 
Contrast and the kidney - Dr. Gawad
Contrast and the kidney - Dr. GawadContrast and the kidney - Dr. Gawad
Contrast and the kidney - Dr. Gawad
 
Obesity and the Kidney (Link and Evidence) - Dr. Gawad
Obesity and the Kidney (Link and Evidence) - Dr. GawadObesity and the Kidney (Link and Evidence) - Dr. Gawad
Obesity and the Kidney (Link and Evidence) - Dr. Gawad
 
Thrombotic Microangiopathy (TMA) in Adults and Acute Kidney Injury - Dr. Gawad
Thrombotic Microangiopathy (TMA) in Adults and Acute Kidney Injury - Dr. GawadThrombotic Microangiopathy (TMA) in Adults and Acute Kidney Injury - Dr. Gawad
Thrombotic Microangiopathy (TMA) in Adults and Acute Kidney Injury - Dr. Gawad
 
Asymptomatic Hyperuricemia with CKD (To Treat or Not To Treat) - Dr. Gawad
Asymptomatic Hyperuricemia with CKD (To Treat or Not To Treat) - Dr. GawadAsymptomatic Hyperuricemia with CKD (To Treat or Not To Treat) - Dr. Gawad
Asymptomatic Hyperuricemia with CKD (To Treat or Not To Treat) - Dr. Gawad
 
Focal Segmental Glomerulosclerosis - FSGS (KDIGO 2021 Guidelines) - Dr. Gawad
Focal Segmental Glomerulosclerosis - FSGS (KDIGO 2021 Guidelines) - Dr. GawadFocal Segmental Glomerulosclerosis - FSGS (KDIGO 2021 Guidelines) - Dr. Gawad
Focal Segmental Glomerulosclerosis - FSGS (KDIGO 2021 Guidelines) - Dr. Gawad
 
Insights from the FIGARO-DKD and FIDELIO-DKD trials - Dr. Gawad
Insights from the FIGARO-DKD and FIDELIO-DKD trials - Dr. GawadInsights from the FIGARO-DKD and FIDELIO-DKD trials - Dr. Gawad
Insights from the FIGARO-DKD and FIDELIO-DKD trials - Dr. Gawad
 
Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. Gawad
Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. GawadDiabetes Mellitus Management in CKD (Clinical Tips) - Dr. Gawad
Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. Gawad
 
Electrolytes & Acid-Base Disturbance Workshop - Dr. Gawad
Electrolytes & Acid-Base Disturbance Workshop - Dr. GawadElectrolytes & Acid-Base Disturbance Workshop - Dr. Gawad
Electrolytes & Acid-Base Disturbance Workshop - Dr. Gawad
 
Dysproteinemias Related Renal Disorders, Monoclonal Gammopathy (Paraproteinem...
Dysproteinemias Related Renal Disorders, Monoclonal Gammopathy (Paraproteinem...Dysproteinemias Related Renal Disorders, Monoclonal Gammopathy (Paraproteinem...
Dysproteinemias Related Renal Disorders, Monoclonal Gammopathy (Paraproteinem...
 
CKD Progression (Pharmacological Approach) - Dr. Gawad
CKD Progression (Pharmacological Approach) - Dr. GawadCKD Progression (Pharmacological Approach) - Dr. Gawad
CKD Progression (Pharmacological Approach) - Dr. Gawad
 
Hypocalcemia (Practical Approach) - Dr. Gawad
Hypocalcemia (Practical Approach) - Dr. GawadHypocalcemia (Practical Approach) - Dr. Gawad
Hypocalcemia (Practical Approach) - Dr. Gawad
 
Hyperkalemia (Practical Approach) - Dr. Gawad
Hyperkalemia (Practical Approach) - Dr. GawadHyperkalemia (Practical Approach) - Dr. Gawad
Hyperkalemia (Practical Approach) - Dr. Gawad
 
Hypernatremia (Practical Approach) - Dr. Gawad
Hypernatremia (Practical Approach) - Dr. GawadHypernatremia (Practical Approach) - Dr. Gawad
Hypernatremia (Practical Approach) - Dr. Gawad
 
Hyponatremia (Practical Approach) - Dr. Gawad
Hyponatremia (Practical Approach) - Dr. GawadHyponatremia (Practical Approach) - Dr. Gawad
Hyponatremia (Practical Approach) - Dr. Gawad
 
Catheter Related Blood Stream Infection (CRBSI) - (Diagnosis & Management Ste...
Catheter Related Blood Stream Infection (CRBSI) - (Diagnosis & Management Ste...Catheter Related Blood Stream Infection (CRBSI) - (Diagnosis & Management Ste...
Catheter Related Blood Stream Infection (CRBSI) - (Diagnosis & Management Ste...
 
Autosomal Dominant Polycystic Kidney Disease (ADPKD) / Emerging Concepts and ...
Autosomal Dominant Polycystic Kidney Disease (ADPKD) / Emerging Concepts and ...Autosomal Dominant Polycystic Kidney Disease (ADPKD) / Emerging Concepts and ...
Autosomal Dominant Polycystic Kidney Disease (ADPKD) / Emerging Concepts and ...
 
AVF/AVG Monitoring and Examination (Applied Clinical Cases) - Dr. Gawad
AVF/AVG Monitoring and Examination (Applied Clinical Cases) - Dr. GawadAVF/AVG Monitoring and Examination (Applied Clinical Cases) - Dr. Gawad
AVF/AVG Monitoring and Examination (Applied Clinical Cases) - Dr. Gawad
 

Recently uploaded

VIII.1 Nursing Interventions to Promote Healthy Psychological responses, SELF...
VIII.1 Nursing Interventions to Promote Healthy Psychological responses, SELF...VIII.1 Nursing Interventions to Promote Healthy Psychological responses, SELF...
VIII.1 Nursing Interventions to Promote Healthy Psychological responses, SELF...
JRRolfNeuqelet
 
Physiologic Anatomy of Heart_AntiCopy.pdf
Physiologic Anatomy of Heart_AntiCopy.pdfPhysiologic Anatomy of Heart_AntiCopy.pdf
Physiologic Anatomy of Heart_AntiCopy.pdf
MedicoseAcademics
 
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose AcademicsCytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
MedicoseAcademics
 
Forensic medicine MCQ for early learners
Forensic medicine MCQ for early learnersForensic medicine MCQ for early learners
Forensic medicine MCQ for early learners
AlaguPandi5
 
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan 081901222272 Obat Penggugur Kandu...
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan  081901222272 Obat Penggugur Kandu...Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan  081901222272 Obat Penggugur Kandu...
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan 081901222272 Obat Penggugur Kandu...
Halo Docter
 

Recently uploaded (20)

Top 10 Most Beautiful Chinese Pornstars List 2024
Top 10 Most Beautiful Chinese Pornstars List 2024Top 10 Most Beautiful Chinese Pornstars List 2024
Top 10 Most Beautiful Chinese Pornstars List 2024
 
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptxCreeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
 
VIII.1 Nursing Interventions to Promote Healthy Psychological responses, SELF...
VIII.1 Nursing Interventions to Promote Healthy Psychological responses, SELF...VIII.1 Nursing Interventions to Promote Healthy Psychological responses, SELF...
VIII.1 Nursing Interventions to Promote Healthy Psychological responses, SELF...
 
Stereochemistry & Asymmetric Synthesis.pptx
Stereochemistry & Asymmetric Synthesis.pptxStereochemistry & Asymmetric Synthesis.pptx
Stereochemistry & Asymmetric Synthesis.pptx
 
Histopathological staining techniques used in liver diseases
Histopathological staining techniques used in liver diseasesHistopathological staining techniques used in liver diseases
Histopathological staining techniques used in liver diseases
 
Physiologic Anatomy of Heart_AntiCopy.pdf
Physiologic Anatomy of Heart_AntiCopy.pdfPhysiologic Anatomy of Heart_AntiCopy.pdf
Physiologic Anatomy of Heart_AntiCopy.pdf
 
spinal cord disorders and paraplegia .
spinal cord disorders  and  paraplegia .spinal cord disorders  and  paraplegia .
spinal cord disorders and paraplegia .
 
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose AcademicsCytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
 
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depthsUnveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
 
Storage of Blood Components- equipments, effects of improper storage, transpo...
Storage of Blood Components- equipments, effects of improper storage, transpo...Storage of Blood Components- equipments, effects of improper storage, transpo...
Storage of Blood Components- equipments, effects of improper storage, transpo...
 
supply cas 5449-12-7 BMK glycidic acid(powder) in stock EU pick-up
supply cas 5449-12-7 BMK glycidic acid(powder) in stock EU pick-upsupply cas 5449-12-7 BMK glycidic acid(powder) in stock EU pick-up
supply cas 5449-12-7 BMK glycidic acid(powder) in stock EU pick-up
 
Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024
 
Forensic medicine MCQ for early learners
Forensic medicine MCQ for early learnersForensic medicine MCQ for early learners
Forensic medicine MCQ for early learners
 
Top 15 Sexiest Pakistani Pornstars with Images & Videos
Top 15 Sexiest Pakistani Pornstars with Images & VideosTop 15 Sexiest Pakistani Pornstars with Images & Videos
Top 15 Sexiest Pakistani Pornstars with Images & Videos
 
Treatment Choices for Slip Disc at Gokuldas Hospital
Treatment Choices for Slip Disc at Gokuldas HospitalTreatment Choices for Slip Disc at Gokuldas Hospital
Treatment Choices for Slip Disc at Gokuldas Hospital
 
ESC HF 2024 Spotlights Day-2.pptx heart failure
ESC HF 2024 Spotlights Day-2.pptx heart failureESC HF 2024 Spotlights Day-2.pptx heart failure
ESC HF 2024 Spotlights Day-2.pptx heart failure
 
SEMESTER-V CHILD HEALTH NURSING-UNIT-1-INTRODUCTION.pdf
SEMESTER-V CHILD HEALTH NURSING-UNIT-1-INTRODUCTION.pdfSEMESTER-V CHILD HEALTH NURSING-UNIT-1-INTRODUCTION.pdf
SEMESTER-V CHILD HEALTH NURSING-UNIT-1-INTRODUCTION.pdf
 
Drug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptxDrug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptx
 
Overview on the Automatic pill identifier
Overview on the Automatic pill identifierOverview on the Automatic pill identifier
Overview on the Automatic pill identifier
 
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan 081901222272 Obat Penggugur Kandu...
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan  081901222272 Obat Penggugur Kandu...Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan  081901222272 Obat Penggugur Kandu...
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan 081901222272 Obat Penggugur Kandu...
 

Membranous Nephropathy - Dr. Gawad

  • 1. Membranous Nephropathy (4 Parts) Mohammed Abdel Gawad Nephrologist – Alexandria - Egypt Founder & Chairman of NephroTube drgawad@gmail.com
  • 2. To download the lecture with full animations contact me drgawad@gmail.com For more Nephrology lectures visit www.NephroTube.com
  • 3. Membranous Nephropathy Part 1 Presentation & Pathogenesis Mohammed Abdel Gawad Nephrologist – Alexandria - Egypt Founder & Chairman of NephroTube drgawad@gmail.com
  • 4. Membranous Nephropathy • Glomerular disease: –Nephrotic syndrome in 60% to 70% –Normal or mildly elevated blood pressure at presentation –Urine: • Benign urinary sediment • Nonselective proteinuria Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
  • 5.
  • 6. Membranous Nephropathy • Subepithelial Immune deposits of IgG and complement Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
  • 7. Membranous Nephropathy • Etiology: Primary (two third of cases) Secondary Kidney Int Suppl. 2012;2:139-274
  • 11. My Starting Point A biopsy proven diagnosis of Membranous Nephropathy (MN)
  • 12. Talk Outline Steps of Management of MN (Diagnosis & Treatment) Evaluation of secondary causes Therapy: Secondary: Treat the cause Idiopathic: Specific Treatment To go through evaluation of secondary causes we have to discuss first Clinically applied Pathophysiology of MN Kidney Int Suppl. 2012;2:139-274
  • 13. Subepithelial deposits MN Possible Mechanisms Glassock RJ. N Engl J Med 2009;361:81-83. Possible Mechanisms of the Formation of Subepithelial Deposits in Experimental Models of, and Patients with, Membranous Nephropathy. 1ry MN2ry MN 2ry MN
  • 14. Subepithelial deposits MN Possible Mechanisms Glassock RJ. N Engl J Med 2009;361:81-83. Possible Mechanisms of the Formation of Subepithelial Deposits in Experimental Models of, and Patients with, Membranous Nephropathy. 1ry MN2ry MN 2ry MN
  • 15. Animal Model - Heymann nephritis Megalin Quigg RJ. Kidney Int 2003; 64:2318.
  • 16. Congenital MN have been shown to be mediated by an antibody to neutral endopeptidase (NEP), an antigen expressed on the podocyte membrane. In these cases, mothers with a hereditary absence of NEP become sensitized during pregnancy and passively transfer anti-NEP IgG to the infant, who is born with congenital nephrotic syndrome caused by MN through an alloimmune mechanism Human Podocyte Antigens Neutral Endopeptidase
  • 18. Human Podocyte Antigens Thrombospondin type - 1 domain - containing 7A (THSD7A) • A transmembrane protein expressed on podocytes. • Responsible Ab in 10% of primary MN with negative anti-PLA2R Ab. Gödel M et al. N Engl J Med 2015; 372:1073. Iwakura T et al. PLoS One 2015; 10:e0138841.
  • 19. Mechanism of primary MN Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
  • 20. Mechanism of primary MN Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16. Qu Z et al. Nephrol Dial Transplant 27: 1931–1937, 2012
  • 21. Mechanism of primary MN Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
  • 22. Characteristics of Primary MN Pathogenesis • Anti PLAR2 Ab. • Th2 Humoral immunity. • IgG4 subclass. • C5b9 (MAC)
  • 23. Characteristics of Primary MN Pathogenesis • Anti PLAR2 Ab. • Th2 Humoral immunity. • IgG4 subclass. • C5b9 (MAC)
  • 24.
  • 25.
  • 26.
  • 27. Serum PLA2R auto antibodies test is a good +ve but not good -ve marker for MN. Anti-PLA2R Titers Clinical Significance (1)
  • 28. Anti-PLA2R Titers Clinical Significance (2) • anti-PLA2R titers strongly correlated with clinical status • lower anti-PLA2R titers were associated with a higher rate of spontaneous remission • a decline in anti-PLA2R predicted the clinical response to immunosuppressive therapy Hofstra JM et al. Clin J Am Soc Nephrol 2011; 6:1286. Hofstra JM et al. J Am Soc Nephrol 2012; 23:1735. Ruggenenti P et al. J Am Soc Nephrol 2015; 26:2545.
  • 29.
  • 30. Anti-PLA2R Is it only related to Idiopathic MN? J Am Soc Nephrol 22: 1137–1143, 2011.
  • 31. Anti-PLA2R Titers Clinical Significance (3) • Highly suggestive of primary MN • But does not exclude the coexistence of: –hepatitis virus infection, –malignancy, –another associated rheumatologic or inflammatory disease. J Am Soc Nephrol 22: 1137–1143, 2011.
  • 33. Membranous Nephropathy (Part 2) Diagnosis (Primary vs Secondary) Mohammed Abdel Gawad Nephrologist – Alexandria - Egypt Founder & Chairman of NephroTube drgawad@gmail.com
  • 34. Talk Outline Steps of Management of MN (Diagnosis & Treatment) Evaluation of secondary causes Therapy: Secondary: Treat the cause Idiopathic: Specific Treatment Kidney Int Suppl. 2012;2:139-274
  • 35. 1- Biopsy 1ry MN Subepithelial IgG subclass 4 Anti PLA2R 2ry MN - Ig other than IgG (e.g. IgA, IgM), particularly in mesangium, subendothelial, tubular BM deposits. - C1q deposits - tubuloreticular structures in the glomerular endothelial cells
  • 36. Serum anti PL 3- Age 4th to 5th decade (suggesting 1ry pathology, but not excluding 2ry causes) - ANA - Anti dsDNA - HBsAg - HCV Ab - Cryoglobulins - RF - C3 - C4 - ESR - CRP If not 4th to 5th decade (suggesting 2ry pathology, but not excluding 1ry causes) Tumor screening: When to screen ? How to screen? Laurence H Beck, Richard J Glassock. UpTodate. Oct 21, 2015.
  • 37. Serum anti PL 3- Age 4th to 5th decade (suggesting 1ry pathology, but not excluding 2ry causes) - ANA - Anti dsDNA - HBsAg - HCV Ab - Cryoglobulins - RF - C3 - C4 - ESR - CRP If not 4th to 5th decade (suggesting 2ry pathology, but not excluding 1ry causes) Tumor screening: When to screen ? How to screen? Laurence H Beck, Richard J Glassock. UpTodate. Oct 21, 2015. Serum complement is usually normal in idiopathic MN
  • 38. Serum anti PL 3- Age 4th to 5th decade (suggesting 1ry pathology, but not excluding 2ry causes) - ANA - Anti dsDNA - HBsAg - HCV Ab - Cryoglobulins - RF - C3 - C4 - ESR - CRP If not 4th to 5th decade (suggesting 2ry pathology, but not excluding 1ry causes) Tumor screening: When to screen ? How to screen? Take care of what is called PURE MEMBERANOUS LUPUS NEPHROPATHY where no clinical or serological evidence of SLE. Laurence H Beck, Richard J Glassock. UpTodate. Oct 21, 2015.
  • 39. Malignancy Screening When to screen? If the anti-PLA2R antibody test is negative + the kidney histology is consistent with secondary MN + there is no other clear cause of secondary MN + risk factors or alarm signs: • extensive smoking history, • guaiac-positive stools, • unexplained anemia or weight loss Laurence H Beck, Richard J Glassock. UpTodate. Oct 21, 2015.
  • 40. Malignancy Screening How to screen? Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
  • 41. Malignancy Screening How to screen? Examination: - LN. - Systemic exam for any mass. - CXR - USS Abd & Pelvis - CBC - Occult blood in stool Male > 50 = PSA Female > 50 = Mammogram Body CT Scan (± other imaging) if cause is not evident
  • 42. Malignancy Screening Frequency of screening Cancer screening should continue for a period of five to ten years after the diagnosis of MN (since cancers associated with MN are typically diagnosed within this time frame.) Laurence H Beck, Richard J Glassock. UpTodate. Oct 21, 2015.
  • 43.
  • 44. Membranous Nephropathy (Lecture 4) Management – Practical Approach Mohammed Abdel Gawad Nephrologist - Alexandria - Egypt Founder & Chairman of NephroTube drgawad@gmail.com
  • 45. Talk Outline Steps of Management (Diagnosis & Treatment) Evaluation of secondary causes Therapy: Secondary: Treat the cause Idiopathic: Specific Treatment Kidney Int Suppl. 2012;2:139-274
  • 46. Spontaneous complete remission of proteinuria 5 to 30 % at five years Spontaneous partial remission 25 to 40 % at five years End-stage renal disease in untreated patients 14 % at five years, 35 % at 10 years, 41 % at 15 years Possibility of Remission Jha V et al. J Am Soc Nephrol 2007; 18:1899.
  • 47. MN - Risk Categories Low Risk Medium Risk High Risk Serum creatinine and creatinine clearance Normal Normal or near-normal Deteriorating renal function Proteinuria <4 g/day 4-8 g/day >8 g/day Supportive treatment period over 6 months of supportive care over 6 months of supportive care over 3-6 months of supportive care Fernando C. Clin J Am Soc Nephrol 3: 905-919, 2008
  • 48. IMN – Treatment Algorithm Kidney Int Suppl. 2012;2:139-274 Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
  • 49. IMN – Treatment Algorithm Kidney Int Suppl. 2012;2:139-274 Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
  • 50. IMN – Treatment Algorithm Kidney Int Suppl. 2012;2:139-274 Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
  • 51. IMN – Treatment Algorithm Kidney Int Suppl. 2012;2:139-274 Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
  • 52. IMN – Treatment Algorithm Kidney Int Suppl. 2012;2:139-274 Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013) Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16.
  • 53. IMN – Treatment Algorithm Kidney Int Suppl. 2012;2:139-274 Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
  • 54. Claudio Ponticelli, Richard J. Glassock. CJASN. 2014 Mar;9(3):609-16. l
  • 55. IMN – Treatment Algorithm Kidney Int Suppl. 2012;2:139-274 Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
  • 56.
  • 57. J Am Soc Nephrol. 2016 Oct 24 low =14–86 U/ml; moderate =87–204 U/ml; high ≥204 U/ml.
  • 58. J Am Soc Nephrol. 2016 Oct 24
  • 59. Repeat Kidney Biopsy Kidney Int Suppl. 2012;2:139-274
  • 60.
  • 61. Membranous Nephropathy (Part 4) Management – Practical Approach (Rituximab) Mohammed Abdel Gawad Nephrologist - Alexandria - Egypt Founder & Chairman of NephroTube drgawad@gmail.com
  • 62. IMN – Treatment Algorithm Kidney Int Suppl. 2012;2:139-274 Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
  • 63. IMN – Treatment Algorithm Kidney Int Suppl. 2012;2:139-274 Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013)
  • 69. 2017 Sep;28(9):2729-2737 4 weekly doses of 375 mg/m2 RTX infused intravenously
  • 70. 2017 Sep;28(9):2729-2737 The dashed lines describe the events in RTX-treated patients 4 weekly doses of 375 mg/m2 RTX infused intravenously
  • 71. N Engl J Med 2019;381:36-46. 130 patients who had membranous nephropathy
  • 72. N Engl J Med 2019;381:36-46. 130 patients who had membranous nephropathy
  • 73. N Engl J Med 2019;381:36-46.
  • 74. N Engl J Med 2019;381:36-46.
  • 75. N Engl J Med 2019;381:36-46.
  • 76. N Engl J Med 2019;381:36-46.
  • 77. N Engl J Med 2019;381:36-46.
  • 78.
  • 79. IMN – Treatment Algorithm Kidney Int Suppl. 2012;2:139-274 Hofstra, J. M. et al. Nat. Rev. Nephrol. 9, 443–458 (2013) Alternative: Rituximab