Patient handout

Membranous Nephropathy

PRODUCTION

1. Your condition

This handout is for membranous nephropathy. Your care team identified this based on: gradual onset nephrotic syndrome — edema + heavy proteinuria + hypoalbuminemia (kdigo 2021 gn).

Other reasons your team may use this plan: adult-onset nephrotic-range proteinuria upcr >3.5 g/g (kdigo 2021 gn); positive serum pla2r antibody — primary mn biomarker (beck nejm 2009); renal biopsy with subepithelial immune deposits + gbm thickening + spike formation (kdigo 2021 gn).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
lisinopril	10 mg PO daily, titrate to max tolerated (typically 40 mg)	PO	daily	KDIGO 2021 GN — RAS blockade max-dose foundational; ~30% spontaneous remission at 12-18 months
losartan	50-100 mg PO daily	PO	daily	KDIGO 2021 GN — ARB alternative

Plan: Membranous nephropathy risk-stratified ladder — low/moderate conservative 6 mo → high-risk rituximab (MENTOR) / Ponticelli CY-steroid / CNI → secondary cause-directed → universal anticoag + statin + vaccinations (KDIGO 2021 GN; MENTOR Fervenza NEJM 2019; Beck PLA2R NEJM 2009)

3. When to call your provider

Contact your care team if any of the following happen:

VTE/PE/RVT confirmed → ED + therapeutic anticoag + admit if PE (KDIGO 2021 GN)
Rising PLA2R titer despite therapy → treatment failure → switch class (RTX↔CY) (Beck 2009)
Rapid eGFR decline → ED + repeat biopsy consideration (KDIGO 2021 GN)
Active sediment + new low complement + positive ANA → reroute to renal.lupus-nephritis.v1 (KDIGO 2021 GN)
CKD progression toward ESRD → transplant evaluation (KDIGO 2024 CKD)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Primary idiopathic PLA2R-positive MN — ~70% of primary; antibody titer correlates with activity; PLA2R IHC on biopsy is highly specific (Beck NEJM 2009)
Primary THSD7A-positive MN — ~3% of primary; higher malignancy association in some series — age-appropriate cancer screen mandatory (KDIGO 2021 GN)
Primary NELL1-positive MN — ~5%; older patients; malignancy-associated in many series; intensified cancer screen (KDIGO 2021 GN)
Secondary lupus class V membranous — full-house IF (IgG/IgM/IgA/C3/C1q); positive ANA + anti-dsDNA + low complement; route renal.lupus-nephritis.v1 (KDIGO 2021 GN)
Secondary HBV- or HCV-associated MN — treat underlying virus first (entecavir/tenofovir for HBV; DAA for HCV); antiviral often improves MN without immunosuppression (KDIGO 2021 GN)
Secondary malignancy-associated MN — solid tumors 5-10% (lung, colon, breast, prostate, gastric); age-appropriate cancer screen + treat tumor (KDIGO 2021 GN)
Pregnancy-associated MN — CY/MMF teratogenic; rituximab risk-benefit case-by-case; close maternal-fetal medicine + nephrology comanagement (KDIGO 2021 GN)
MN has highest VTE/RVT/PE risk of any nephrotic cause — albumin <2.5 g/dL → anticoag prophylaxis (warfarin INR 2-3 or DOAC); PE with hemodynamic compromise → ICU + thrombolysis (KDIGO 2021 GN; Lin nephrotic anticoag)(life-threatening)

5. Follow-up

q3-6 month nephrology; post-transplant MN recurrence ~10%; CV/bone/fertility; PLA2R antibody monitoring for relapse prediction; transplant evaluation if approaching ESRD (KDIGO 2024 CKD)

6. Sources

Guideline: KDIGO 2021 Glomerular Diseases + MENTOR rituximab (NEJM 2019) + GEMRITUX (JASN 2017) + STARMEN (Kidney Int 2021) + anti-PLA2R antibody (Beck NEJM 2009)