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Comparative efficacy of 13 immunosuppressive agents for idiopathic membranous nephropathy in adults with nephrotic syndrome: a systematic review and network meta-analysis
  1. Qiyan Zheng1,2,
  2. Huisheng Yang3,
  3. Weijing Liu2,4,
  4. Weiwei Sun2,4,
  5. Qing Zhao1,2,
  6. Xiaoxiao Zhang1,2,
  7. Huanan Jin2,
  8. Luying Sun2,4
  1. 1First Clinical Medical College, Beijing University of Chinese Medicine, Beijing, China
  2. 2Department of nephrology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
  3. 3Institute of Acupuncture and Moxibustion, China Academy of Chinese Medicine Science, Beijing, China
  4. 4Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
  1. Correspondence to Dr Luying Sun; luyingsun{at}


Objectives This study aimed to compare the effectiveness of 13 types of immunosuppressive agents used to treat idiopathic membranous nephropathy (IMN) in adults with nephrotic syndrome.

Design Systematic review and network meta-analysis.

Data sources PubMed, EMbase, Cochrane Library, Web of Science, Clinical trials, SinoMed, Chinese Biomedicine, CNKI, WanFang and Chongqing VIP Information databases were comprehensively searched until February 2018.

Eligibility criteria Randomised clinical trials (RCTs) comparing the effects of different immunosuppressive treatments in adult patients with IMN and nephrotic syndrome were included, and all included RCTs had a study-duration of at least 6 months.

Data extraction and synthesis Two reviewers independently screened articles, extracted data and assessed study quality. Standard pairwise meta-analysis was performed using DerSimonian-Laird random-effects model.

Results This study ultimately included 48 RCTs with 2736 patients and 13 immunosuppressive agents. The network meta-analysis results showed that most regimens, except for leflunomide (LEF), mizoribine (MZB) and steroids (STE), showed significantly higher probabilities of total remission (TR) when compared with non-immunosuppressive therapies (the control group),with risk ratios (RRs) of 2.71 (95% CI) 1.81 to 4.06)for tacrolimus+tripterygium wilfordii (TAC+TW), 2.16 (1.27 to 3.69) foradrenocorticotropic hormone, 2.02 (1.64 to 2.49) for TAC, 2.03 (1.13 to3.64) for azathioprine (AZA), 1.91 (1.46 to 2.50) for cyclosporine (CsA), 1.86 (1.44 to2.42) for mycophenolate mofetil (MMF), 1.85 (1.52 to 2.25) for cyclophosphamide (CTX),1.81 (1.10 to 2.98) for rituximab (RIT), 1.80 (1.38 to 2.33) for TW, 1.72 (1.35 to 2.19) for chlorambucil. As for 24 hours UTP, the direct andindirect comparisons showed that AZA (standard mean difference (SMD), −1.02(95% CI −1.90 to −0.15)), CsA (SMD, −0.70 (95% CI −1.33 to −0.08)),CTX (SMD, −1.01 (95% CI −1.44 to -0.58)), MMF (SMD, −0.98 (95% CI −1.64 to −0.32)), MZB (SMD, −0.97 (95% CI −1.90 to−0.04]), TAC (SMD, −1.16 (95% CI −1.72 to −0.60)) and TAC+TW(SMD, −2.03 (95% CI −2.94 to −1.12)) could significantly superior thancontrol, except for chlorambucil, LEF, RIT and STE. Thechanges of serum creatinine (Scr) was not significantly different between eachtreatments of immunosuppressive agents and the control, except for STE whichhas the possibility of increasing Scr (SMD, 1.00 (95% CI 0.36 to 1.64)).Comparisons among all treatments of immunosuppressive agents showed nostatistical significance in the outcome of relapse. A drenocorticotropichormone (85.1%) showed the lowest probability of relapse under the cumulativeranking curve values among all immunosuppressants. Infection,gastrointestinal symptoms, and bone marrow suppression were the common adverseevents associated with most of the immunosuppressive therapies.

Conclusions This study demonstrates that TAC+TW, TAC and CTX are superior to other immunosuppressive agents in terms of TR and 24 hours UTP. Moreover, they are all at risk of infection, gastrointestinal symptoms, and myelosuppression. Furthermore, TAC could increase the risk of glucose intolerance or new-onset diabetes mellitus. Conversely, STE alone, LEF and MZB seem to have little advantage in clinical treatment of IMN.

PROSPERO registration number CRD42018094228.

  • nephrology
  • immunology
  • clinical trials

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  • QZ, HY and WL contributed equally.

  • Contributors All authors take responsibility for the integrity of the data and the accuracy of data analysis. Study concept and design: YLS and QZ. Protocol design: YLS and HY. Literature retrieval and data extraction: QZhe, QZha, XZ and HJ. Statistical analysis: HY, QZ and WS. Interpretation of data: HY, QZhe, and WL. Drafting of the manuscript: QZ and HY. Quality assessment: HY, WS and WL. Critical revision of the manuscript: YLS, WL and WS. Technical support: HY and WL. All authors have read and agreed to the submission to this journal of the manuscript.

  • Funding This study was supported by National Major Scientific and Technological Special Project for 'Significant New Drugs Development' (No. 2017Z×09304019).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplementary information.