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Abstract: PO1862

Cryoglobulinemia After Hepatitis C Virus Eradication

Session Information

Category: Trainee Case Report

  • 1203 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Silva Santisteban, Andy Louis, University of Miami School of Medicine, Miami, Florida, United States
  • Zuo, Yiqin, University of Miami School of Medicine, Miami, Florida, United States
  • Chavez Morales, Efren Alejandro, University of Miami School of Medicine, Miami, Florida, United States
Introduction

Mixed cryoglobulinemia (cryo) is often caused by HCV infection. Major clinical manifestations are arthralgias, myalgias, palpable purpura, peripheral neuropathy and glomerulonephritis (GN). Diagnostic evaluation may reveal the presence of serum cryoglobulins, rheumatoid factor (RF) and hypocomplementemia. If diagnosis is uncertain tissue biopsy with histologic confirmation may be useful. The treatment of patients with HCV-related cryo GN involves eradication of HCV infection with direct-acting antiviral agents (DAAs) and immunosuppression for more severe systemic disease. Some patients develop persistent or relapsing disease despite a sustained virologic response (SVR) with DAAs rarely leading to life-threatening manifestations.

Case Description

We report a case of a 76-year-old female with chronic HCV infection treated with DAAs with SVR for years referred to nephrology clinic for evaluation of CKD and nephritic syndrome. She also reported pain and a purpuric papular rash on her legs. Labs showed hypocomplementemia and high levels of RF. Cryo was suspected, but repeated testing of serum cryoglobulins was negative. Renal biopsy showed membranoproliferative GN with endocapillary hypercellularity and intracapillary “cryo-plugs” by LM, and IgM dominant with kappa greater than lambda capillary loop and mesangial staining by IF, and subendothelial and mesangial deposits by EM. These findings suggest cryo GN. Patient was treated with a prednisone taper and rituximab. She had a rapid improvement in renal function, complete remission of proteinuria and normalization of complement levels.

Discussion

Mixed cryo should be considered in the differential diagnosis in the appropriate clinical setting in patients with HCV infection even after treatment and prolonged SVR. To detect serum cryoglobulins blood should be collected in a prewarmed tube without anticoagulant. Inadequate technique may lead to false-negative results.

Renal Biopsy. Cryoglobulinemic Glomerulonephritis