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Background Membranous nephropathy is the chief etiology of nephrotic syndrome in adults. It is clinically featured and presented by investigational tool as very high of protein levels in urine, edema, hypoalbuminemia and elevated serum level. Idiopathic membranous nephropathy is a chronic pathological form of clinical scenarios and its pathophysiological course involves spontaneous remissions or remissions by immunosupressions with frequent relapses. Aim To assess the efficiency of Rituximab as a secondary line immunosuppression in Patients with Idiopathic Membranous Nephropathy (IMN) who failed to respond to Ponticelli regimen and to compare it with Cyclosporine. Methods This study is a retrospective cohort study including 40 Egyptian patients with biopsy proven IMN who failed primary immunosuppression with cyclophosphamide and steroids according to Ponticelli regimen divided into two equal groups, 20 patients each. Cyclosporine Group: received Cyclosporine, given daily for a minimum of 6 months at doses of 3.5 mg/kg orally and Rituximab Group: received Rituximab weekly for 4 weeks at doses of 375 mg/m2 intravenously. Data collected included UPCR, eGFR, serum albumin, serum creatinine, CBC, lipid profile for 6 times: before giving cyclosporine or rituximab (time 0), after 1month, 3, 6,9 and 12 months. Results 17 patients achieved remission (7 CR and 10 PR) in CSA treated group while 13 patients (1 CR and 12 PR) in RTX group, P = 0.077. UPCR was reduced for &amp;gt;50% in patients receiving Cyclosporine compared to 30% in Rituximab treated group: UPCR was decreased from 5.9±3.5 at time 0 to 2.0±2.8 (p = 0.002) &amp; decreased from 7.3±5.2 to 4.6±3.9 (P = 0.031) in Cyclosporine and Rituximab groups respectively. There was improvement of serum albumin in both groups by the end of study more remarkable in cyclosporine group. The eGFR was non significantly reduced by the end of study in RTX group while it showed significant reduction in CSA group. No serious adverse events were reported all through the study period in both groups. Conclusion Rituximab is an efficient, well tolerated secondary immunosuppressant drug in IMN. Its effect is comparable to CSA regarding remission induction. It induces better results than CSA regarding effect on eGFR but worse results regarding proteinuria improvement. Individualization of immunosuppressant use in IMN should be considered.

Rituximab and Cyclosporine in Idiopathic Membranous Nephropathy Who Failed to Respond to Ponticelli Regimen