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Kidney Week

Abstract: TH-PO702

I Am the Lucky Third: Spontaneous Resolution of High-Risk Membranous Nephropathy

Session Information

Category: Glomerular Diseases

  • 1402 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Bin Homam, Wadhah Mohammed, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
  • Ayub, Fatima, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
  • Elkalashy, Ahmed, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
  • Hasan, Md Rajibul, Arkansas College of Osteopathic Medicine, Fort Smith, Arkansas, United States
  • Holthoff, Joseph H., University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States

Group or Team Name

  • UAMS Internal Medicine/Nephrology.
Introduction

The 2021 KDIGO guidelines for the treatment of high-risk and very high-risk membranous nephropathy (MN) involve angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers, and intense immunosuppression with rituximab or combination of cyclophosphamide and steroids. Typically, these immunosuppression regimens are initiated immediately in high-risk and very high-risk MM. Here we present a case of very high-risk MN nephropathy who achieved spontaneous with only conservative management.

Case Description

A 28-year-old male with no significant past medical history presented with acute onset of left flank pain and lower limb swelling for 3 weeks. Pertinent lab workup showed proteinuria of 28 grams/day, serum albumin of 1.1g/dL, and normal serum creatinine. CT angiogram showed bilateral renal veins thrombosis extending to the inferior vena cava. The serological workup for glomerulonephritis came back positive for anti-PLA2R antibodies, hence diagnosing him with primary MN. Renal biopsy further confirmed MN and PLA2R stain was diffusely positive The patient underwent an interventional radiology-guided thrombectomy. Given the severity of his clinical picture and following a detailed discussion of the risks versus benefits of different protocols of immunosuppressants, a pulsed dose of methylprednisolone was administered followed by oral prednisone for modified Ponticelli regimen, but the patient later refused cyclophosphamide due to the risk of infertility and agreed with initiating of rituximab. However, the prior authorization for rituximab was unsuccessful, and the patient was discharged on a tapered course of prednisone, lisinopril, and apixaban. At six-month follow-up, proteinuria was reduced to 1.6 g/d and renal function remained stable.

Discussion

Here we present a case of very high-risk MN in which the patient achieved spontaneous remission and remained in partial remission at the 6-month follow-up visit. Cases such as this highlight the fact that risk stratification in MN is based on criteria at the time of initial diagnosis, when in fact the disease may follow a dynamic and changing course over time.Just as low and moderate risk patients may ultimately progress to renal failure, here we present a case of very high risk MN that ultimately achieved remission without intensive immune suppression.