Abstract: TH-PO627

Successful Twin Pregnancy in a Patient with IgA Nephropathy and Nephrotic Range Proteinuria

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Niznik, Robert Stanislaw, Mayo Clinic, Rochester, Minnesota, United States
  • Kattah, Andrea G., Mayo Clinic, Rochester, Minnesota, United States
  • Garovic, Vesna D., Mayo Clinic, Rochester, Minnesota, United States
Background

There is literature for using tacrolimus in patients with IgA nephropathy for anti-proteinuric effect in those that cannot tolerate ACE inhibitors due to hypotension. We present a case of tacrolimus use in pregnancy primarily for anti-proteinuric effects.

Methods

This is a 29 year old female with a history of IgA nephropathy diagnosed in 2003. A renal biopsy at the time showed a small fibrocellular crescent. She was initially treated with steroids; however, she experienced significant side effects and this was discontinued after 3 days. Subsequently, she was treated with lisinopril, irbesartan and omega-3 fatty acid with improvement of her 24 hr urine protein, blood pressure and 24 hour creatinine clearance. She then had a recurrence of subnephrotic proteinuria in May of 2012 and was treated with Myfortic with improvement in proteinuria.

In 2015, she desired pregnancy and so a repeat biopsy was done, showing focal glomerulosclerosis and minimal mesangial changes (M1 E0 S0 T0). She had 1.3g/24 hr of proteinuria and a creatinine of 1.0. Her Myfortic and lisinopril were stopped and nifedipine was initiated for hypertension. Unfortunately, she had rapid worsening of her proteinuria off of the ACE inhibitor up to 5.9g/24 hrs and refused steroids. She had decreased levels of TPMT and so was started on a low dose of azathioprine for immunosuppression. She continued to have worsening disease activity with 10g of proteinuria and dysmorphic hematuria and so low-dose tacrolimus (trough 2-4) was started with improvement in proteinuria to 4g/24 hrs. She then naturally conceived a twin pregnancy and had a full term delivery without complications.

Conclusion

Intolerance to steroids and contraindication to mycophenolate in addition to low TPMPT limited the therapeutic options in this case. Using tacrolimus for its antiproteinuric effects at low dose can be beneficial.

Light microscopy with PAS stain showing IgA nephropathy with mild mesangial
proliferative changes and focal global glomerulosclerosis