Pharmacological management of membranous nephropathy

When steroids and immunosuppressive drugs were the only available pharmacological agents used to treat membranous nephropathy, nephrologists were polarized into two groups, those supporting therapy on the basis of the results achieved in controlled trials and those opposed to therapy who contended that the side-effects of therapy were too severe to consider in a disease with a relatively benign course. These two groups are drawing closer as treatments with lesser side-effects emerge. The demonstration that proteinuria accelerates progressive kidney failure in all renal diseases led to a major focus on control of proteinuria. Angiotensin-converting enzyme inhibitors, diuretics and angiotensin II receptor antagonists all play a role. Older methods of treatment that reduce proteinuria are being resurrected. A major development is the demonstration in a randomized study that cyclosporin A is effective in membranous nephropathy. Therefore, although there has been no major recent breakthrough or novel therapeutic agent used in membranous nephropathy, a range of new methods of controlling proteinuria provide some compromise between therapeutic enthusiasm and conservative management in this common disorder.