Proteinuria >3.5 g, periorbital edema, ↓albumin (normal PT = not liver)
Confirm: anti-PLA2R (positive serology can replace biopsy in classic nephrotic syndrome with preserved eGFR; monitor titers for immunologic response); urine protein; biopsy if atypical/declining GFR = membranous
Treat: ACE inhibitor + statin + diuretic; immunosuppression (steroids/cyclophosphamide/rituximab)
Anticoagulation: prophylactic only when serum albumin <25 g/L (<20–25 with membranous, KDIGO 2021) plus additional risk, unless bleeding risk high; therapeutic anticoagulation for any thromboembolic event
Order set
- Urine PCR
- Albumin, lipids
- U&E
- anti-PLA2R
- Renal biopsy
Criteria
AdmitAKI, thromboembolism, severe oedema
DischargeOedema controlled, anticoagulation decided, immunosuppression + follow-up
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Thromboembolism (renal vein/PE)
- AKI
- Severe edema
Differentials
- Minimal change
- FSGS
- Diabetic nephropathy
- Amyloid
Common mistakes
- Forgetting VTE risk
- Missing secondary causes (malignancy, drugs)
Disposition & follow-up
ACEi, statin, diuretics ± immunosuppression; anticoagulate high-risk.
Discharge package
MedicationsACEi/ARB, statin, diuretic ± immunosuppression; anticoagulation if high-risk
Follow-upNephrology
Warning symptomsLeg/chest pain or SOB (clots), severe oedema
💊 Treatment detail — doses & preparation
LisinoprilACE inhibitor
DoseStart 2.5–5 mg OD, target 20–40 mg OD
Preparation2.5/5/10/20 mg tablets
MonitorCreatinine + K⁺ 1–2 wk after each titration
Furosemide POloop diuretic
Dose20–80 mg OD/BD, titrate to dry weight
Preparation20/40/500 mg tablets; take morning/midday
MonitorDaily weight, K⁺, renal function
ImmunosuppressionKDIGO 2021
DoseMembranous nephropathy (moderate/high risk): rituximab 1 g IV ×2 (2 wk apart) or modified Ponticelli (alternating monthly methylprednisolone + cyclophosphamide ×6 mo); cyclophosphamide-rituximab combo for very high risk
Preparation5/25 mg tablets; gastro-resistant or plain with food
MonitorGlucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Atorvastatinstatin
Dose20–80 mg OD (post-ACS 80 mg)
Preparation10/20/40/80 mg tablets, any time of day
MonitorLFTs baseline, muscle symptoms; target LDL reduction ≥50%
📖 KDIGO Glomerular DiseasesReviewed July 2026