Approach Considerations

In secondary membranous nephropathy, successful treatment of the underlying cause may be curative. For example, in hepatitis-associated membranous nephropathy, antivirals may be useful.^{[24, 25]}

Symptomatic treatment includes the following:

A low-salt diet is key to reducing anasarca. Protein restrictions may or may not be useful in reducing the rate of progression of kidney dysfunction.
Diuretics help control edema. Loop diuretics are used most often.
Treat hypertension aggressively.
Statins help treat hypercholesterolemia.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can help to decrease the proteinuria; however, NSAIDs have been largely supplanted by angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). ACE inhibitors decrease proteinuria and control hypertension; use ARBs for patients intolerant of ACE inhibitors.

Routine anticoagulation is controversial. However, the risk of renal vein thrombosis and other deep vein thromboses is significant, and the clinician must be vigilant in monitoring for signs of venous thromboembolism (VTE). Once VTE is found, anticoagulation is generally continued indefinitely. In a study of membranous nephropathy, the risk of developing VTE increased 3.9-fold with a reduction in serum albumin below the threshhold of 2.8 g/dL and 5.8-fold with a serum albumin of less than 2.2 g/dL.^[26]

Treatment is guided by risk category (see Overview/Prognosis). Do not treat patients with asymptomatic nonnephrotic proteinuria with immunosuppressives. Patients who are asymptomatic and nephrotic may undergo remission, particularly if they have normal kidney function and an early lesion. They may also be observed.

Therapy with immunosuppressive agents (see Medication) is indicated in those patients who have the following:

Increased creatinine level at presentation
Progressive disease
Severe symptomatic nephrotic syndrome
Persistent nephrotic syndrome
Thromboembolism
Persistent nephrotic syndrome, male sex, and age older than 50 years
Increased IgG excretion, HLA-DR3 ⁺/B8 ⁺, white race, and elevation of urinary excretion of complement activation products
Tubulointerstitial changes or focal sclerosis

Kidney transplantation is indicated if the patient progresses to end-stage kidney disease. Some risk of recurrence in the allograft is recognized.

Medication

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