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Abstract: SA-PO752

Don't Miss Mesalamine! Mesalamine-Induced Focal Segmental Glomerulosclerosis in a Patient With Ulcerative Colitis

Session Information

Category: Glomerular Diseases

  • 1304 Glomerular Diseases: Podocyte Biology

Author

  • Linares, Andrea Rubi, Cleveland Clinic Florida, Weston, Florida, United States

Group or Team Name

  • Department of Kidney Medicine
Introduction

Renal manifestation in UC and Crohn’s disease is not uncommon. It’s suggested to be a combination of genetic factors, infectious agents, bacterial endotoxins, and immune complex depositions. The most frequent renal disease in patients with IBD are nephrolithiasis, TIN, GN, and amyloidosis. Mesalamine is a 5-ASA compound which is the mainstay drug for UC. It is known to cause hypersensitivity reactions which may even cause aggravation of UC.

Case Description

We present a case of a 23 year old male with a history of UC for 8 years who went to the ED for worsening generalized edema for 3 days. His UA with 3+ protein and no RBCs. UPCR was 7.2 and albumin 1.6 g/dL. Nephrology was consulted for nephrotic syndrome. IV diuresis was started for anasarca. The patient had been taking mesalamine for many years and did not have recent UC flare ups. He did not have history of premature birth, hypertension, or obesity, and had normal kidney size. Urine microscopy showed oval fat bodies. Serological work up was significant for elevated ESR, + MPO and +PR3 antibodies. HIV, CMV, EBV, and parvovirus B19 were negative.
A native kidney biopsy was done and it revealed negative IF findings and evidence against active immune complex mediated GN. EM confirmed diffuse podocyte effacement and ultimately glomerular tip lesion variant Focal Segmental Glomerulosclerosis. The patient was started on immunosuppression with corticosteroids, RAAS blockade with ARB, Calcium/ Vitamin D supplementation, PPI, diuretics, and salt restriction. With close outpatient monitoring and tapering of steroids, the patient’s proteinuria and edema improved. He continues to follow up with GI and will pursue other treatments for UC once steroids have been completely tapered.

Discussion

IBD renal manifestations are usually associated with disease activity and improve with remission of bowel inflammation. Lack of viral causes or UC activity, as well as postive MPO and PR3 antibodies, was more suggestive of a drug induced reaction. Mesalamine is renally excreted and the most common reported kidney related adverse reactions is acute or chronic interstitial nephritis due to hypersensitivity reaction usually occurring in the first 6 months of use. Mesalamine induced FSGS must be considered in the differential early on presentation of a patient with nephrotic syndrome to ensure adequate and appropriate treatment to preserve kidney function.