Which of the following is an initial management step for membranous nephropathy?

• A. Exclude/treat underlying causes
• B. RAAS inhibitors (ACE inhibitors or ARBs) for renal protection
• C. Prednisone PLUS another immunosuppressant (eg, cyclophosphamide, mycophenolate)
• D. Dialysis is not indicated unless kidney failure occurs

Answer: (B)

Membranous nephropathy often presents with nephrotic-range proteinuria, and the first priority is kidney protection while addressing the disease process. Blocking the renin-angiotensin-aldosterone system with ACE inhibitors or ARBs is the best initial step because these drugs reduce intraglomerular pressure, decrease proteinuria, and slow the decline in renal function. They also help control hypertension and can alleviate edema, which are important in a nephrotic patient.

If the nephropathy is secondary to another condition (such as an infection, autoimmune disease, or drug exposure), that underlying cause should be addressed, but supportive renal protection with RAAS blockade remains the foundational first move. Immunosuppressive therapy (like steroids plus another immunosuppressant) is considered after evaluating risk and response to supportive care, not as the initial management. Dialysis becomes necessary only if kidney failure develops, not as an initial step.