KDIGO Guidelines for Glomerular Diseases: Membranous Nephropathy

KDIGO guidelines have been now published on glomerular diseases in KI this year
(image source: kidneypathology.com)
Topic: Membranous Nephropathy

1. Initial therapy should only be started on patients with nephrotic syndrome and one of the following: more than 4g/day of proteinuria AND remains over 50% of the baseline value, AND does not show progressive decline, during anti hypertensive and proteinuric therapy with 6 months of observation( Grade 1B) or presence of disabling or severe complication of nephrotic syndrome( clot, significant edema)( Grade 1C) or rise in creatinine by 30% or more in 6-12 months from time of diagnosis (Grade 2C).

2. Immunosuppresive therapy to be not used if chronic disease found with small kidneys on sonogram.
3. 6 months of modified Pontecelli regimen ( oral or IV cyclophosphamide and steroids) for 6 months( Grade 1B) as initial therapy. Steroid month starts with IV steroids (1gm) for 3 days followed by oral steroids( 0.5mg/kg/day) for 27 days. The cyclo month starts and finishes with 2.0mg/kg/day of oral for 30 days.
4. CNI can be used for 6 months if cannot use above Pontecelli regimen( Grade 1C). CNI dose be reduced by month 2 to a level of about 50% of starting dose provided remission is maintained and no treatment related nephrotoxicity is develping( Grade 2C).
5. For resistant cases, suggesting switching from alkylating regimen based to CNI based and vice versa.
6. Relapses should be treated with the same therapy that worked ( Grade 2D).
7. If an alkylating therapy was used initially, then that regimen should only be used one more time again. (Grade 2B).
8. Nephrotic syndrome with albumin <2.5g/dl and additional risks for thrombosis,may benefit from warfarin ( 2C).

For full paper see: http://www.nature.com/kisup/journal/v2/n2/pdf/kisup201220a.pdf