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Kidney Week

Abstract: TH-PO204

HCV-Associated Glomerulopathy and Cryoglobulinemia Despite Sustained Remission of Hepatitis C Viremia after Treatment with Oral Direct-Acting Antiviral Agents

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Akhtar, Rabia, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
  • Handelsman, Cory, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
  • Walker, John A., Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
Background

Millions of people are infected with chronic hepatitis C worldwide. Aside from hepatic injury, hepatitis C virus infection may be associated with a multitude of extrahepatic complications. These include lymphoproliferative disorders (including essential mixed cryoglobulinemia, monoclonal gammopathies and lymphoma), dermatologic conditions such as lichen planus and porphyria cutanea tarda, and glomerular disease.

Methods

We present a case of a 47 year old woman who developed worsening azotemia, nephrotic-range proteinuria, hypocomplementemia, and mixed cryoglobulinemia nearly one year after demonstrating a sustained remission of hepatitis C viremia (genotype 1A) following treatment with the oral direct acting anti-viral agent Harvoni (ledipasvir/sofosbuvir). Kidney biopsy revealed extensive duplication of the glomerular basement membrane on light microscopy, predominant mesangial and capillary wall IgA deposits on immunofluorescence, and extensive dense subendothelial deposits on electron microscopy, consistent with a histologic diagnosis of a hepatitis C virus associated membranoproliferative glomerulonephritis with immune complex deposition. Hepatitis C RNA PCR was negative at the time of the biopsy,

Conclusion

This case is noteworthy in that our patient developed a hepatitis C virus associated membranoproliferative glomerulonephritis with immune complex deposition in the setting of mixed cryoglobulinemia despite achieving a sustained remission of hepatitis C viremia 1 year earlier. Another intriguing and unusual feature of our case is that in membranoproliferative glomerulonephritis, immune complex depositions typically consist of IgG and C3, whereas in our patient the predominant immunoglobulin present was IgA. This case suggests that the immunostimulatory effects of hepatitis C infection may persist or recur despite a successful course of antiviral therapy, and these effects may be responsible for post-treatment glomerular injury.