In what clinical circumstances do you use repository corticotropin injections in the management of a glomerulonephritis?

Personally, I have never used ACTH gel, but two specific disease states come to mind: steroid-resistant FSGS and membranous nephropathy. In one study, the partial remission rate for steroid-resistant FSGS was 29%, and for post-transplant recurrence of FSGS, 55%. For MN, the complete remission rate was 27%, and the partial remission rate was 55%, but in the era of obinitizumab, the response rate is >80% in MN.

ACTH is known to stimulate cortisol secretion from the adrenal cortex; however, it is also thought to bind to melanocortin receptors on podocytes, mesangial cells, and endothelial cells, thereby exerting antiproteinuric effects. Despite its potential benefits, ACTH gel is quite expensive, and the porcine-derived ACTH can be immunogenic...