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Membranous Nephropathy Treatment — RACP Adult Medicine MCQ

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HardNephrologyMembranous Nephropathy TreatmentRACP Adult Medicine

A 40-year-old man presents with nephrotic syndrome. Renal biopsy shows positive IgG and C3 staining in a granular pattern along the glomerular basement membrane on immunofluorescence. Electron microscopy shows subepithelial deposits. Serology for hepatitis B, lupus, and malignancy is negative. Anti-PLA2R antibodies are positive. What is the preferred initial treatment for high-risk membranous nephropathy?

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Correct answer: E — ACEi/ARB only and observe for 6 months

Rituximab is increasingly used as first-line immunosuppressive therapy for primary membranous nephropathy (PLA2R-positive) with high-risk features (proteinuria >4 g/day with declining eGFR or persistently elevated anti-PLA2R titres). The MENTOR trial showed non-inferiority of rituximab to ciclosporin with superior sustained remission at 24 months. The STARMEN trial and RI-CYCLO trial provide additional supportive evidence. Anti-PLA2R titre monitoring guides treatment response. Supportive therapy (ACEi/ARB, statins) should be optimised in all patients regardless.

Reference: KDIGO – 2021 – Glomerular Diseases Guidelines; MENTOR Trial – 2019