Treatment of Primary FSGS and MCD in Elderly Patients

Initial Management and Immunosuppression

The American College of Physicians recommends initiating ACE inhibitor or ARB at maximally tolerated dose regardless of baseline blood pressure in elderly patients with primary FSGS or MCD presenting with nephrotic range proteinuria 1, 3
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest targeting systolic blood pressure ≤125/80 mmHg or <120 mmHg using standardized measurement in patients with nephrotic syndrome 3, 4
The National Kidney Foundation recommends adding thiazide diuretic if blood pressure remains elevated in patients with nephrotic syndrome 1
The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) suggests loop diuretics (furosemide) as first-line agent for severe edema and anasarca in patients with nephrotic syndrome 5
The American Heart Association recommends initiating statin therapy for cholesterol control in patients with nephrotic syndrome 1, 4

The KDIGO guidelines state that immunosuppression should only be considered in idiopathic FSGS or MCD with nephrotic syndrome when proteinuria remains >4 g/day AND stays at >50% of baseline value despite 3-6 months of maximal conservative therapy 1, 3, 2
The American College of Cardiology recommends considering calcineurin inhibitors as first-line therapy rather than high-dose corticosteroids due to the elderly population's increased risk of steroid-related complications 1, 2
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) suggests that cyclosporine is preferred over tacrolimus due to lesser tendency to precipitate diabetes in patients with FSGS or MCD 1, 10

The Centers for Disease Control and Prevention (CDC) recommends pneumococcal vaccination (23-valent or conjugate vaccine), annual influenza vaccination, and herpes zoster vaccination before starting immunosuppressive therapy in patients with nephrotic syndrome 5, 4
The Infectious Diseases Society of America (IDSA) suggests screening for latent tuberculosis, hepatitis B/C, and HIV before initiating immunosuppression in patients with nephrotic syndrome 4
The KDIGO guidelines recommend trimethoprim-sulfamethoxazole prophylaxis during immunosuppression in patients with nephrotic syndrome 4