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Abstract: SA-PO727

A Novel Approach in a Case of Cryoglobulinemic Glomerulonephritis

Session Information

Category: Glomerular Diseases

  • 1303 Glomerular Diseases: Clinical‚ Outcomes‚ and Trials

Authors

  • Kalantri, Pooja, Emory University, Atlanta, Georgia, United States
  • Lomashvili, Koba A., Emory University, Atlanta, Georgia, United States
Introduction

Obinutuzumab, a fully humanized monoclonal anti CD-20 antibody, has been used for the treatment of B-cell malignancies. It is a novel and attractive treatment option in cases of glomerulonephritis, when Rituximab, a chimeric humanized murine monoclonal anti CD-20 antibody is not tolerated.

Case Description

A 52-year-old lady had a history of hypertension, Sjogren's disease, and mixed cryoglobulinemia complicated by glomerulonephritis and vasculitis. She reported being diagnosed with this disease in 2008 needing plasmapheresis. She relapsed in summer of 2020, with severe renal and skin manifestation and responded well to Rituximab infusion in August of 2020, achieving full remission with subsequent doses of rituximab at 4 months intervals. Unfortunately, the patient developed severe serum sickness reaction to third dose of Rituximab, requiring intubation. She relapsed again in 7/2021, and was diagnosed with monoclonal paraproteinemia of IgM kappa type with a normal bone marrow biopsy, 29% cryoglobulin levels, worsening proteinuria, AKI and purpuric rash with skin ulcers. She got pulse steroids and was started on monthly IV Cytoxan and oral steroid taper. The patient improved initially, dropping cryoglobulin level to 3%, but relapsed again when prednisone was tapered to 20 mg, while receiving IV Cytoxan. Prednisone was increased back to 60 mg daily. She later got admitted with a large left lower extremity ulcer and worsening skin rash. Her cryoglobulin level was also up to 8%. She was started on pulse dose steroids again and 1000mg Obinutuzumab given IV, with which she went into remission within 3 months. She got her second dose 5 months later on 3/2022, with prednisone completely tapered off currently. She had a healed leg ulcer, resolving purpuric rash, proteinuria of 330 mg/day, negative cryoglobulins, and an improving histopathology as of 3/2022.

Discussion

Rituximab is a chimeric antibody with murine and human components in it. Obinutuzumab is a fully humanized form. We believe that our patient had a reaction to the murine component of rituximab, which was not present in Obinutuzumab and hence she tolerated it well. It is a good alternative to explore. Obinutuzumab is currently not FDA approved for the treatment of cryoglobulinemic glomerulonephritis, and is being investigated for the treatment of lupus nephritis and membranous nephropathy.