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| ==Overview== | | ==Overview== |
| [[Lipid]] lowering and [[anticoagulation]] for better [[blood]] flow. [[Diuretics]] to reduce [[edema]]. [[ACE inhibitor]] or an angiotensin II receptor blocker (ARB) are recomended to reduce renal vascular damage.
| | Pharmacologic medical therapy is recommended among patients who has infectious, autoimmune causes of membranous glomerulonephritis. The preferred regimen is prednisone (0.5 mg/kg per day) with cyclophospamide IV for 3-5 months. Blood pressure can be controlled in patients with membranous glomerulonephritis usually requires more than [[angiotensin]] inhibition alone. |
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| ==Medical Therapy== | | ==Medical Therapy== |
| Following recommendations are advised while dealing with patient suffering membranous glomerulonephritis '''MGN'''<ref name="pmid29852477">{{cite journal| author=Bomback AS, Fervenza FC| title=Membranous Nephropathy: Approaches to Treatment. | journal=Am J Nephrol | year= 2018 | volume= 47 Suppl 1 | issue= | pages= 30-42 | pmid=29852477 | doi=10.1159/000481635 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29852477 }}</ref><ref name="pmid22859855">{{cite journal| author=Waldman M, Austin HA| title=Treatment of idiopathic membranous nephropathy. | journal=J Am Soc Nephrol | year= 2012 | volume= 23 | issue= 10 | pages= 1617-30 | pmid=22859855 | doi=10.1681/ASN.2012010058 | pmc=3458460 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22859855 }}</ref><ref name="pmid10495797">{{cite journal |vauthors=Wasserstein AG |title=Membranous glomerulonephritis |journal=J. Am. Soc. Nephrol. |volume=8 |issue=4 |pages=664–74 |date=April 1997 |pmid=10495797 |doi= |url=}}</ref> | | Following is the treatment of membranous glomerulonephritis.<ref name="pmid29852477">{{cite journal| author=Bomback AS, Fervenza FC| title=Membranous Nephropathy: Approaches to Treatment. | journal=Am J Nephrol | year= 2018 | volume= 47 Suppl 1 | issue= | pages= 30-42 | pmid=29852477 | doi=10.1159/000481635 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29852477 }}</ref><ref name="pmid22859855">{{cite journal| author=Waldman M, Austin HA| title=Treatment of idiopathic membranous nephropathy. | journal=J Am Soc Nephrol | year= 2012 | volume= 23 | issue= 10 | pages= 1617-30 | pmid=22859855 | doi=10.1681/ASN.2012010058 | pmc=3458460 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22859855 }}</ref><ref name="pmid10495797">{{cite journal |vauthors=Wasserstein AG |title=Membranous glomerulonephritis |journal=J. Am. Soc. Nephrol. |volume=8 |issue=4 |pages=664–74 |date=April 1997 |pmid=10495797 |doi= |url=}}</ref> |
| | | *Pharmacologic medical therapy is recommended among patients who has infectious, autoimmune causes of membranous glomerulonephritis. |
| * [[Lipid]] lowering and [[anticoagulation]] for better blood flow | | *Pharmacologic medical therapies for membranous glomerulonephritis include (either) , antihypertensive therapy, anticoagulative therapy, antihyperlipid or immunosuppresion therapy. |
| * [[Diuretics]] to reduce [[edema]] | | *Patients with autoimmune are treated with immunosuppressive therapy. |
| * [[Angiotensin inhibition]] | | *Patients with proteinuria are treated with antihypertensive and hyperlipidmic therapy. |
| * [[ACEi|ACE inhibitor]] or an [[angiotensin II]] receptor blocker are recomended to reduce [[renal]] [[vascular]] damage | | === First-line immunosuppressive therapy: === |
| | * The first line of immuneosuppressive therapy is given below:<ref name="pmid29852477" /><ref name="pmid22859855" /><ref name="pmid10495797" /> |
| | * The preferred regimen is prednisone (0.5 mg/kg per day) with cyclophospamide IV for 3-5 months. |
| | * Methylprednisolone (0.4 mg/kg per day) given with cyclophosphamide (2.0 to 2.5 mg/kg per day) given IV for 2, 4, and 6 months. |
| | * Tacrolimus (0.05 mg/kg per day for) PO for 12 months with a six-month taper. |
| | * Rituximab (3.5g/day) IV for 6-12 months. |
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| === Treatment for proteinuria: === | | === Treatment for proteinuria: === |
| * The optimal [[proteinuria]] goal in patients with [[chronic kidney disease]] is less than 1000 mg/day<ref name="pmid29852477">{{cite journal| author=Bomback AS, Fervenza FC| title=Membranous Nephropathy: Approaches to Treatment. | journal=Am J Nephrol | year= 2018 | volume= 47 Suppl 1 | issue= | pages= 30-42 | pmid=29852477 | doi=10.1159/000481635 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29852477 }}</ref><ref name="pmid22859855">{{cite journal| author=Waldman M, Austin HA| title=Treatment of idiopathic membranous nephropathy. | journal=J Am Soc Nephrol | year= 2012 | volume= 23 | issue= 10 | pages= 1617-30 | pmid=22859855 | doi=10.1681/ASN.2012010058 | pmc=3458460 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22859855 }}</ref><ref name="pmid10495797">{{cite journal |vauthors=Wasserstein AG |title=Membranous glomerulonephritis |journal=J. Am. Soc. Nephrol. |volume=8 |issue=4 |pages=664–74 |date=April 1997 |pmid=10495797 |doi= |url=}}</ref> | | * The treatment for proteinuria is given below:<ref name="pmid29852477" /><ref name="pmid22859855" /><ref name="pmid10495797" /> |
| * Attainment of partial remission can result from one or more of the following:
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| === Hpertensive managment: ===
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| * The goal blood pressure in patients with membranous glomerulonephritis is the same as it is in other patients with proteinuric chronic kidney disease<ref name="pmid29852477">{{cite journal| author=Bomback AS, Fervenza FC| title=Membranous Nephropathy: Approaches to Treatment. | journal=Am J Nephrol | year= 2018 | volume= 47 Suppl 1 | issue= | pages= 30-42 | pmid=29852477 | doi=10.1159/000481635 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29852477 }}</ref><ref name="pmid22859855">{{cite journal| author=Waldman M, Austin HA| title=Treatment of idiopathic membranous nephropathy. | journal=J Am Soc Nephrol | year= 2012 | volume= 23 | issue= 10 | pages= 1617-30 | pmid=22859855 | doi=10.1681/ASN.2012010058 | pmc=3458460 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22859855 }}</ref><ref name="pmid10495797">{{cite journal |vauthors=Wasserstein AG |title=Membranous glomerulonephritis |journal=J. Am. Soc. Nephrol. |volume=8 |issue=4 |pages=664–74 |date=April 1997 |pmid=10495797 |doi= |url=}}</ref>
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| * Blood pressure can be controlled in patients with membranous glomerulonephritis usually requires more than [[angiotensin]] inhibition alone
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| * Volume overload cab be controlled well with [[loop diuretics]]
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| * A low-salt diet is an important component of [[antihypertensive]] therapy (especially when using [[angiotensin inhibitors]]) and edema control in patients with MN | | ==== Hpertensive managment: ==== |
| * A high-salt diet can increase proteinuria.
| | * The goal blood pressure in patients with membranous glomerulonephritis is the same as it is in other patients with proteinuria chronic kidney disease. |
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| === Treatment for hyperlipidemia: ===
| | * [[angiotensin]] inhibitior (ACEi) for |
| * [[Statins]] are the drug of choice for the patient with membranous glomerulonephritis<ref name="pmid29852477">{{cite journal| author=Bomback AS, Fervenza FC| title=Membranous Nephropathy: Approaches to Treatment. | journal=Am J Nephrol | year= 2018 | volume= 47 Suppl 1 | issue= | pages= 30-42 | pmid=29852477 | doi=10.1159/000481635 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29852477 }}</ref><ref name="pmid22859855">{{cite journal| author=Waldman M, Austin HA| title=Treatment of idiopathic membranous nephropathy. | journal=J Am Soc Nephrol | year= 2012 | volume= 23 | issue= 10 | pages= 1617-30 | pmid=22859855 | doi=10.1681/ASN.2012010058 | pmc=3458460 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22859855 }}</ref><ref name="pmid10495797">{{cite journal |vauthors=Wasserstein AG |title=Membranous glomerulonephritis |journal=J. Am. Soc. Nephrol. |volume=8 |issue=4 |pages=664–74 |date=April 1997 |pmid=10495797 |doi= |url=}}</ref> | | * [[loop diuretics]] for |
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| === Treatment for coagulation: === | | ===== Treatment for hyperlipidemia: ===== |
| * Patients with [[nephrotic syndrome]], particularly those with membranous glomerulonephritis, are at increased risk for thrombotic events, such as deep vein and renal vein thrombosis or pulmonary embolism.<ref name="pmid29852477">{{cite journal| author=Bomback AS, Fervenza FC| title=Membranous Nephropathy: Approaches to Treatment. | journal=Am J Nephrol | year= 2018 | volume= 47 Suppl 1 | issue= | pages= 30-42 | pmid=29852477 | doi=10.1159/000481635 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29852477 }}</ref><ref name="pmid22859855">{{cite journal| author=Waldman M, Austin HA| title=Treatment of idiopathic membranous nephropathy. | journal=J Am Soc Nephrol | year= 2012 | volume= 23 | issue= 10 | pages= 1617-30 | pmid=22859855 | doi=10.1681/ASN.2012010058 | pmc=3458460 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22859855 }}</ref><ref name="pmid10495797">{{cite journal |vauthors=Wasserstein AG |title=Membranous glomerulonephritis |journal=J. Am. Soc. Nephrol. |volume=8 |issue=4 |pages=664–74 |date=April 1997 |pmid=10495797 |doi= |url=}}</ref> | | * [[Statins]] PO. |
| * A low serum albumin concentration not the degree of proteinuria is suggestive of a venous thromboembolic event
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| * Compared with patients who had a serum albumin concentration greater than 2.8 g/dL, the risk of an event was 2.5-fold greater in patients with a serum albumin concentration below 2.8 g/dL
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| * All patients who have a [[thromboembolic]] event should be treated initially with low molecular weight or unfractionated heparin, followed by oral anticoagulation (eg, warfarin), the same regimen used for patients without nephrotic syndrome who have deep vein thrombosis or a pulmonary embolism
| | ===== Treatment for coagulation: ===== |
| | | * Low molecular weight or unfractionated heparin, followed by PO low molecular warfarin. |
| === First-line immunosuppressive therapy: ===
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| * [[Cyclophosphamide]] plus [[glucocorticoids]] or a [[Calcineurin inhibitor|calcineurin]] inhibitor with low-dose or no glucocorticoids<ref name="pmid29852477">{{cite journal| author=Bomback AS, Fervenza FC| title=Membranous Nephropathy: Approaches to Treatment. | journal=Am J Nephrol | year= 2018 | volume= 47 Suppl 1 | issue= | pages= 30-42 | pmid=29852477 | doi=10.1159/000481635 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29852477 }}</ref><ref name="pmid22859855">{{cite journal| author=Waldman M, Austin HA| title=Treatment of idiopathic membranous nephropathy. | journal=J Am Soc Nephrol | year= 2012 | volume= 23 | issue= 10 | pages= 1617-30 | pmid=22859855 | doi=10.1681/ASN.2012010058 | pmc=3458460 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22859855 }}</ref><ref name="pmid10495797">{{cite journal |vauthors=Wasserstein AG |title=Membranous glomerulonephritis |journal=J. Am. Soc. Nephrol. |volume=8 |issue=4 |pages=664–74 |date=April 1997 |pmid=10495797 |doi= |url=}}</ref>
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| * [[Rituximab]] may be used with resistant patients | |
| * A random [[urine]] protein-to-[[creatinine]] ratio should not be used as initial and follow-up test to measure the progress of treatment
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| * Patients with less than 4.0 g/day on a 24-hour urine collection should not be treated with immunosuppressive therapy. They should be monitored periodically for disease progression every three months for two years and twice yearly
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| * Patients with protein excretion between 4.0 and 8.0 g/day on a 24-hour urine collection undergo spontaneous complete or partial remission over a period of three to six years
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| * [[Glucocorticoids]] alone are not effective
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| * Other drugs include [[mycophenolate mofetil]], [[intravenous immune globulin]], and synthetic [[adrenocorticotropic hormone]]
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| * [[Cyclophosphamide]] and chlorambucil-based regimens are equally effective
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| * The preferred regimen is oral prednisone (0.5 mg/kg per day) or methylprednisolone (0.4 mg/kg per day) given for months 1, 3, and 5 plus oral cyclophosphamide (2.0 to 2.5 mg/kg per day) given for months 2, 4, and 6
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| * [[Cyclosporine]] plus low-dose [[prednisone]] (maximum of 10 mg/day)
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| * The [[cyclosporine]]-treated group had a significantly higher rate of complete (≤300 mg/day) or partial remission of proteinuria, which is defined as less than 3.5 g/day
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| * Tacrolimus (0.05 mg/kg per day for 12 months with a six-month taper)
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| * [[Rituximab injection|Rituximab]] may have benefit among patients with a moderate risk of progression who have not previously received immunosuppressive therapy
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| ==References== | | ==References== |