What is your approach to immunosuppression in patients with preserved kidney function who are found to have nephrotic syndrome of unknown etiology and cannot safely undergo a kidney biopsy?

In patients with preserved kidney function who have nephrotic syndrome of unknown etiology and cannot safely undergo a kidney biopsy, what steps would you consider in your approach to management?

• Attempt to obtain a kidney biopsy through Interventional Nephrology or Interventional Radiology
• Conduct a comprehensive laboratory workup (including kidney function tests, serum albumin, urine collection, hepatitis B and C, HIV, ANA, PLA2R, etc.)
• Initiate empirical treatment with immunosuppression (e.g., rituximab or high-dose glucocorticoids) based on clinical presentation and lab results
• Provide conservative management (ACEi/ARB, diuretics, BP control, control of blood sugars/lipids, weight loss) and monitor response
• Other