Idiopathic membranous nephropathy (IMN) is the most common form of nephrotic syndrome in adults. Immunosuppressive agents acts predominate in its treatment for its benign or indolent course. As single-use glucocorticoids showed no benefit on IMN 
, several immunosuppressive agents in combination with glucocorticoids widely be used in China, namely CTX, CyA, LET, MMF and TAC. There was no good evidence for the choices of immunosuppressive agents in treating nephrotic IMN.
The object of this meta-analysis was to compare the efficacy and safety of different immunosuppressive in the treatment of Chinese adults with nephrotic IMN, providing some updated references to nephrologists for making optimal therapy. By limiting trials conducted in Chinese adults, we aimed to exclude the interference of ethnic differences on the response to immunosuppressive treatment, as some studies 
showed that Asian might have better prognosis in IMN compared to Caucasian.
None of the studies involved reported the long-term outcome, like mortality or ESRD requiring initiation of dialysis or kidney transplantation. This analysis only viewed the short-term parameters to evaluate efficacy, including the final proteinuria/serum creatinine/serum albumin values and the therapeutic remission of participants (complete remission, partial remission). Serum creatinine is a value determined by multifactor, and has not showed obvious change during short-term follow up. Final proteinuria and serum albumin has correlation with the therapeutic remission, so the authors mainly analysed the latter. The most frequent definition usually adopted for “partial remission” was proteinuria between 0.3–2.0 g/24 h or decreased to lower by half. For “complete remission” the usual definition was proteinuria of less than 0.3 g/24 h and serum albumin more than 35 g/L and a normal renal function. However these definitions can be heterogeneous.
Cyclophosphamide as a classical immunosuppressive agent used in Chinese nephrotic IMN patients, was compared with other relatively new immunosuppressive agents, including LET, MMF, TAC and CyA. There were heterogeneous in the usage of cyclophosphamide: in 3 trials 
received daily oral CTX 100 mg/d for 6 months then reduced half for another 6 months; in the other 12 trials, CTX was given intravenously (1g/month, for single dose or divided into two times). Through the comparison “calcineurin inhibitors versus alkylating agents”, IMN patients showed a better treatment response to calcineurin inhibitors. In the analysis of two different agents, tacrolimus was in optimistic position, showing better response than CTX, statistically significant higher rate on inducing remission than CTX, and with tolerable side effects. When compared to CTX, MMF and CyA induced more response but not significant in inducing complete remission, LET shown no significant difference both on complete remission and complete/partial remission. But only 2 studies involving 116 patients compared CyA with CTX, more high quality RCTs were needed to determine their effects. Only one study was included in the analysis on “TAC versus LET” and “MMF versus modified Ponticelli regimen”, both shown no significant difference.
Sensitivity analysis was performed by excluding low quality trials, did not substantially change the main results. This meta’s result “calcineurin inhibitors inducing more remission than alkylating agents” coincided with the earlier meta 
. “TAC’s favor position” was supported by data from previous TAC monotherapy effect 
. The funnel plots did not show obvious publishing bias of mainly comparisons.
Short-term duration (6–24 mouths), only one trial 
used blindness, not large-sample participants (696 in total), absence comparison between some agents(mostly compared to CTX), no advanced subgroup analyses of different level proteinuria (only definition was “nephrotic”) led to limitations of this meta. The probable explain for non-blindness was those agents have a relative high adverse rate and blood drug concentration level need to be checked. CTX have been compared in most studies, possibly for its classical position.
In conclusion, based on Chinese adults and short duration RCTs, calcineurin inhibitors, especially TAC, showed superior potency to induce remission in nephrotic IMN with tolerable adverse effects, compared to alkylating agent (CTX).