The edition · Nephrology
Obinutuzumab outperformed tacrolimus for complete remission in membranous nephropathy
The phase 3 MAJESTY trial, published in June, found complete remission at two years in 37% with obinutuzumab versus 6% with tacrolimus. Also: the trade-offs of ABO-incompatible kidney transplantation, exercise during dialysis, nandrolone in CKD, and an FDA supplement for finerenone.
The edition in brief
MAJESTY, published in NEJM in June, randomised 142 adults with primary membranous nephropathy to intravenous obinutuzumab or oral tacrolimus. Complete remission at 104 weeks was 37% versus 6% (difference 31 points, 18 to 44), with higher complete or partial remission and similar serious adverse events; sustained eGFR decline did not differ. It supports anti-CD20 therapy over calcineurin inhibitor monotherapy for durable remission. A meta-analysis of 63 observational studies (5852 ABO-incompatible and 47,950 compatible recipients) found ABO-incompatible transplantation had more rejection (RR 1.28) and antibody-mediated rejection (RR 2.14), more bleeding and surgical complications, similar 1-, 3- and 10-year survival, but lower 5-year patient survival. A meta-analysis of 14 trials (934 patients) linked intradialytic exercise to modest gains in ejection fraction, arterial stiffness and peak oxygen uptake, at moderate to low certainty. A meta-analysis of 15 largely historical trials found nandrolone increased lean mass by 2.6 kg in CKD, with very low-certainty evidence for haemoglobin. FDA's database lists a supplement to the finerenone (Kerendia) application; its content is not stated.
ABO-incompatible transplant: similar long-term survival, more rejection and bleeding
ABO-incompatible kidney transplantation offers broadly comparable survival, but plan for more early bleeding and antibody-mediated rejection.
Exercise during haemodialysis: modest cardiovascular gains
Offer intradialytic cycling as a low-cost way to improve fitness and arterial stiffness in haemodialysis patients.
Nandrolone in CKD: more lean mass, uncertain effect on anaemia
Nandrolone may add lean mass in CKD, but evidence is old and weak; it is not an anaemia treatment.
FDA lists a supplement to the finerenone (Kerendia) application
An FDA supplement to the Kerendia application is listed; keep prescribing and monitoring potassium as before until the label is revised.
Using anti-PLA2R titres in membranous nephropathy
Track anti-PLA2R titres every three to six months; they show response and relapse before proteinuria does.
MAJESTY: obinutuzumab achieves more complete remissions than tacrolimus
For primary membranous nephropathy needing immunosuppression, prefer anti-CD20 therapy to tacrolimus alone; obinutuzumab gave six times the complete remission rate.
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