Treatment Options for Membranous Kidney Disease

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Membranous kidney disease presents itself with protein in the urine and swelling of the extremities. Explore treatment options with the help of a practicing nephrologist in this free video.

Part of the Video Series: Kidney & Bladder Health
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Video Transcript

Hey you guys, Dr. Sean Hashmi here with Kaiser Permanente in Woodland Hills. So today, I thought I'd talk to you guys briefly about treatment options for membranous kidney disease. Now this is actually a very complex topic and certainly not enough time in one small video to talk about all of the things but membranous kidney disease is one of the kidney diseases that presents itself with a lot of protein in the urine so people will present to my office with leg swelling or even swelling extending all the way up their arms may be swollen, their face may be puffy and when we do a urine test we find that they're spilling a lot of protein. Often as a consequence of that they may have very high cholesterol to go with it. Their blood pressure may be elevated. So the thing about membranous is what are the causes of it? Well a lot of things, we don't know. Infections can do it, viruses like Hepatitis B, Hepatitis C are associated with it, cancer or solid tumors are associated with membranous disease as well along with a host of other things. But there is something to remember about membranous and this is when we call the rule of thirds. So what is that rule? Well one third of the people who present with membranous will get better, one third kind of stay about the same, maybe progress a little bit and one third will definitely worsen and go all the way to kidney failure. So when you think about treating membranous you have to keep in mind that a third of these patients have the potential to just get better by themselves. So this is why we look at patients with membranous disease and we see how bad is the disease. If it's mild, what we'll end up doing is we'll give them blood pressure control and the medicines we use for controlling blood pressure also lower the protein in the urine. Now what are these medications? These if you remember from previous videos are the Angiotinsen Converting Enzyme Inhibitors or ACE Inhibitors but they all end in pril, Enalapril, Lisinopril, Benazepril. We have Aldosterone Receptor Antagonists or the artan. So tell me, Sartan, Valsartan. These medications will lower the protein. Your doctor may also prescribe you Spironolactone which is an Aldosterone Antagonist and what that will do is also lower the protein and with modern medicine we have new medications coming out, one of them is Aliskiren or Tekturna that can also do similar things. So, if the proteinuria isn't too bad we'll start off as a first line with just blood pressure medications and lower the protein. Why is lowering protein so important? Because it will destroy the kidney if we don't lower the protein. Now the next step is somebody who has a lot of protein being spilled in the urine. What do we do for these people? We've already tried the ACE Inhibitors, the arb's maybe something else on top where we're controlling that but they're protein is still a lot. Well then we will start with steroids and Cytotoxic Agents. So these are the stuff that's designed to shut down your immune system, not completely but to suppress it enough so that we can control the disease. So, the Cytotoxic Agents we use there's a couple of them but the majority or the major one we use is called Cyclophosphamide, the common name for it Cytoxan. So we will give Cytoxan and we will give Prednisone. Often times the regimen is given one month of Cytoxan alternated with one month of Prednisone but you have to be aware, these are very powerful agents and they have a lot of side effects and they must be used extremely carefully and you must understand all the different side effects that they can do. Another agent or line of agents that we use are called Calcineurin Inhibitors. The two that we have on the market right now is Tacrolimus and Cyclosporine. These are the two, so Tacrolimus or Prograf, Cyclosporine has a couple of names it goes by and Gengraf is one of them. These two agents can also be used with Prednisone to treat some of the worst cases of membranous diseases. Why is it so important to treat membranous disease? Because if left alone, one there's a very high risk that it can progress, remember one third of the patients can progress. So if the proteinuria is very bad, we've got to try to save the kidneys. Two is it will cause high blood pressure, it will cause high cholesterol. There is a risk of blood clots and there is a risk of infection with membranous disease because as you lose your protein remember all your immune system, remember your antibodies, these are all protein so you're losing all of that in your urine and making you more susceptible to infections, to blood clots, the things in your body that prevent the blood from clotting are also protein and you are losing that in the urine so your risk of having blood clots goes up. So bottom line, treatment options for membranous kidney disease, start off with blood pressure control with an ACE Inhibitor, arb, if it's very severe then you will have to add Cytoxic agents such as Prednisone and Cytoxan or Calcineurin Inhibitors and Prednisone. Once again this is Dr. Sean Hashmi with Kaiser Permanente in Woodland Hills talking to you about treatment options for membranous kidney disease. Thanks for watching.


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