Long-term ACTH low-dose in a case of membranous nephropathy

Abstract

The anti-proteinuric effect of a synthetic ACTH-analog, Tetracosactide, has been reported in membranous nephropathy resistant to previous treatments with steroids and immunosuppressive agents, as well as in other glomerulonephritis. ACTH-analog induced changes on melanocortin receptors of podocytes are the main antiproteinuric mechanisms of action. Unfortunately, recurrences of nephrotic syndrome are quite common after ACTH-analog discontinuation. We report a case of a 20 years old female patient affected by membranous nephropathy, with nephrotic syndrome and normal renal function, which resulted resistant to steroids and cyclosporine therapy. Then she was treated by Tetracosactide (1 mg i.m. per week, for 12 months): after 6 months complete remission occurred, but a relapse was observed 6 months after the discontinuation of the therapy. A second cycle with Tetracosactide was repeated with a new complete remission after 10 months of therapy. After the one-year treatment period, ACTH-analog was continued using a maintenance dose of 1 mg i.m. once a month: up to now, after 24 months of once-a-month Tetracosactide administration, no relapse, no side effect and no detrimental effect on renal function have been observed. This case suggests that a very low-dose and long-term Tetracosactide administration may be an effective and well tolerated therapeutic chance in patients with nephrotic syndrome resistant to steroid and/or immunosuppressive agents to avoid relapses.