Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

all patients

1st line – low-salt and low-protein diet

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ONGOING
|
all patients
1st line – 

low-salt and low-protein diet

Reducing protein intake to approximately 0.8 g/kg/day based on ideal body weight decreases nephrotic-range proteinuria. However, dietary protein restriction alone is unlikely to induce complete remission of nephrotic syndrome.[23]​ Dietary sodium restriction can help reduce oedema.[1]​

Plus – ACE inhibitor or angiotensin-II receptor antagonist

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ONGOING
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all patients
|
with hypertension
Plus – 

ACE inhibitor or angiotensin-II receptor antagonist

Treatment recommended for ALL patients in selected patient group

ACE inhibitors can reduce proteinuria and slow progression of renal disease and are the preferred medications to treat hypertension.[1][2]​​

Angiotensin II receptor antagonists may be prescribed if ACE inhibitors are not tolerated.

In patients with a significant anti-proteinuric response, the effect is usually seen within 2 months of treatment initiation.

Patients should follow a low-salt diet, because a high intake can significantly impair the beneficial effects of angiotensin II blockade.

Primary options

enalapril: 2.5 mg orally once daily initially, increase according to response, maximum 40 mg/day

OR

lisinopril: 2.5 mg orally once daily initially, increase according to response, maximum 80 mg/day

Secondary options

losartan: 25 mg orally once daily initially, increase according to response, maximum 100 mg/day

OR

irbesartan: 150 mg orally once daily initially, increase according to response, maximum 300 mg/day

Plus – statin

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ONGOING
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all patients
|
with hyperlipidaemia
Plus – 

statin

Treatment recommended for ALL patients in selected patient group

Lipid abnormalities result from increased liver synthesis and urinary loss of regulatory proteins. The resulting increased vascular risk due to lipid abnormalities is an important therapeutic target.[2]​

Statin dose should be reduced when taken concomitantly with ciclosporin.

Primary options

simvastatin: 40 mg orally once daily at night

OR

atorvastatin: 10 mg orally once daily at night

OR

pravastatin: 40 mg orally once daily at night

Plus – furosemide ± hydrochlorothiazide

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ONGOING
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all patients
|
with oedema
Plus – 

furosemide ± hydrochlorothiazide

Treatment recommended for ALL patients in selected patient group

A diuretic is initiated to treat oedema.

Furosemide is first choice and may be used in combination with a thiazide diuretic if oedema cannot be successfully managed with monotherapy.[2]​

It is advisable to check electrolyte levels before treatment is started and to monitor these at follow-up appointments.

Primary options

furosemide: 40-120 mg/day orally given in 2 divided doses

Secondary options

furosemide: 40-120 mg/day orally given in 2 divided doses

and

hydrochlorothiazide: 12.5 to 50 mg orally once daily

Plus – corticosteroid + cytotoxic or immunosuppressive therapy

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ONGOING
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all patients
|
with moderate, high risk, or very high risk of progressive kidney injury
Plus – 

corticosteroid + cytotoxic or immunosuppressive therapy

Treatment recommended for ALL patients in selected patient group

Guidelines suggest initial therapy should consist of a 6-month course of alternating monthly cycles of oral and intravenous corticosteroids, and oral alkylating agents or rituximib.[20]​ The preferred alkylating agent is cyclophosphamide.[20]​ Patients should be managed conservatively for at least 6 months following the completion of this regimen before the treatment is considered to have failed. Patients who choose not to receive the cyclical corticosteroid/alkylating agent regimen, or who have contraindication to this regimen, can be offered ciclosporin or tacrolimus for at least 6 months.[20]

Monthly FBC is recommended while taking cytotoxic or immunosuppressive treatment. See local protocols for guidance on dosing. Prophylaxis for Pneumocystis pneumonia in patients receiving cyclophosphamide and prophylaxis for thrush in patients taking corticosteroids is recommended.

Primary options

prednisolone: consult specialist for guidance on dose

and

cyclophosphamide: consult specialist for guidance on dose

Secondary options

prednisolone: consult specialist for guidance on dose

and

rituximab: consult specialist for guidance on dose

OR

prednisolone: consult specialist for guidance on dose

and

chlorambucil: consult specialist for guidance on dose

Tertiary options

ciclosporin: consult specialist for guidance on dose

OR

tacrolimus: consult specialist for guidance on dose

Plus – treatment of underlying cause

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ONGOING
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all patients
|
with a secondary cause
Plus – 

treatment of underlying cause

Treatment recommended for ALL patients in selected patient group

Around 20% of patients have membranous nephropathy as a result of an underlying condition such as SLE, Sjogren's syndrome, hepatitis B or C, or malignancy (commonly lung or colorectal). Treatment of any underlying cause usually resolves symptoms.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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