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Am I receiving the right treatment for membranous kidney?

Q: I am a 67 years old male diagnosed with membranous kidney two and a half years back, when I was down with E. coli infection with high fever, vomiting, loss of appetite and high blood pressure. I had protein leakage in urine (+ + +). I was initially given wysolone, endoxan, and cardace, in addition to becelac PB for 8 months in varying doses. Telma 20 and Febutaz 40 have been added lately. I wanted to know if I should continue Telma 20 and Febutaz 40 indefinitely. Is there any adverse effect on prolonged use of these medications?

A:Initial treatment with combination of Endoxan (Cyclophosphamide) and Wysolone (Prednisolone) for a few months is appropriate for patients with Membranous Nephropathy who are at moderate to high risk of progression.

You indicated that you had "+++" protein in the urine at disease diagnosis. This limited information suggests to me that you have achieved at least a partial remission of your disease with the Endoxan and Wysolone therapy.

Partial remission is usually defined as urine protein excretion below 3500 mg/day plus a 50 percent or greater reduction in protein excretion from the peak value. A complete remission is usually defined as protein excretion below 300 mg/day.

At this stage, based on the limited information that you have provided, I recommend the following:

  • Maintain you blood pressure below 130/80 mm Hg. Cardace and Telma are both excellent drugs for this. Apart from lowering blood pressure, they also lower protein excretion in the urine and slow the progression of kidney disease in general. However, when using both of them simultaneously, there is an increased risk of high potassium levels in the blood and hence this has to be periodically monitored.

    You are on starting doses of both Cardace (1 mg) and Telma (20 mg). One option available to simplify your regimen is to maximize the dose of Cardace (max dose 10 mg once daily) prior to adding Telma (max dose 40 mg once daily) for blood pressure control. Please discuss further with your nephrologist.

    You will need blood pressure medications as long as your BP is above 130/80 mmHg, to protect your kidneys.
  • Patients who lose a lot of protein in the urine usually have high blood cholesterol levels and it is very important to keep the blood cholesterol levels in the normal range to keep the heart healthy. I would recommend checking fasting blood lipid levels and taking a lipid lowering agent if the levels are high. Please discuss further with your nephrologist.
  • Cancer screening. You should be up-to- date on age-appropriate cancer screening (colonoscopy, prostate specific antigen, etc). The risk of cancer is about 12 to 20 times higher in patients with membranous nephropathy than that observed in the general population. Please discuss further with your nephrologist.
  • Periodic follow-up with a nephrologist to detect any disease recurrence. Relapse of significant protein in the urine occurs in 25 to 30 percent of patients.

You also mentioned that you are taking Febutaz-40 (Sildenafil) and wanted to know if you have to take it indefinitely. Febutaz-40 is usually used to treat erectile dysfunction and / or pulmonary artery hypertension and is most likely unrelated to your Membranous Nephropathy. Please discuss the need for this medicine with your regular physician.

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