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Answer 5
  1. Furosemide and an ACE inhibitor. Treatment of idiopathic membranous nephropathy remains controversial due to a high spontaneous remission rate. Without treatment, generally one third of patients spontaneously remit, one third progress to renal failure, and one third remain unchanged.5 However, several general principles apply to the management of these patients, including diuretics to control edema, angiotensin inhibition to reduce proteinuria, and correction of hyperlipidemia.5 In selected patients with risk factors for progressive disease, such as presence of glomerular scarring, elevated serum creatinine at presentation, and proteinuria greater than 8 g/day, immunosuppressive therapy should be considered; however, glucocorticosteroids alone are not beneficial. Glucocorticosteroids should be combined with alkylating agents or calcineurin inhibitors to attain remission. Warfarin is indicated in patients at high risk for thromboembolism with massive proteinuria and an albumin level less than 2 g/dL and is not the initial step in management of membranous nephropathy.

     Perna A, Schieppati A, Zamora J, et al. Immunosuppressive treatment for idiopathic membranous nephropathy: a systematic review. Am J Kidney Dis 2004;44:385–401.

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