Efficacy and safety of adrenocorticotropic hormone treatment in glomerular diseases: a systematic review and meta-analysis

Background: There is growing evidence that adrenocorticotropic hormone (ACTH) may be effective in treating various forms of glomerular diseases. However, the efficacy of treatment and frequency of adverse effects associated with the use of ACTH in glomerular diseases are unknown. A systematic review and meta-analysis of the literature was performed. Methods: A literature search was performed using Medline, Embase, Google Scholar and the Cochrane Database of Systematic Reviews from inception through 18 July 2015. Studies assessing the efficacy and safety of ACTH treatment in adults with glomerular diseases were included. Results: Of the 343 identified citations, 18 evaluated the drug efficacy and 12 evaluated the adverse effects. The most common glomerular diseases were membranous nephropathy (MN), primary focal segmental glomerulosclerosis (FSGS) and minimal change disease (MCD). The overall rate of complete remission in MN was 80% at 0-6 months, 69% at >6-12 months, 90% at >12-24 months and 95% beyond 24 months of follow-up. Fifty percent of primary FSGS and MCD patients treated with ACTH were in remission at 6 months, but the relapse rate was high after ACTH discontinuation (17%). Evidence of ACTH efficacy for other glomerular diseases was scarce. Edema was the most commonly reported adverse effect {incidence rate [IR] 0.10 [95% confidence interval (CI) 0.04-0.18]} followed by insomnia [IR 0.08 (95% CI 0.03-0.15)]. The dropout rate due to adverse events was 7%, mostly due to edema and weight gain. Conclusions: ACTH is a well-tolerated therapy and is most promising when treating patients with MN. There may be a potential role for ACTH in patients with MCD and FSGS, but data are lacking.