Abstract: TH-PO0514
Breaking Resistance: Successful Treatment of Refractory Nephrotic Syndrome with a Nonstandard Treatment (Upadacitinib)
Session Information
- Glomerular Diseases: IgAN, IgA Vasculitis, and More
October 22, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Author
- Ziaolhagh, Ali, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, United States
Introduction
We present a case of refractory nephrotic syndrome in a 36-year-old Caucasian male with a longstanding history of membranoproliferative glomerulonephritis (MPGN), previously managed with mycophenolic acid.
At age 34, he developed an acute exacerbation with nephrotic syndrome and acute kidney injury. Repeat kidney biopsy revealed membranous nephropathy. Despite treatment with mycophenolic acid, Rituximab, tacrolimus, and corticosteroids, there was no clinical response, and the patient experienced significant medication intolerance.
Given the lack of response and intolerance to conventional regimens, an alternative, non-standard therapy, Upadacitinib, was initiated.
Case Description
He was admitted with anasarca. creatinine 2.9–3.0 (baseline 0.7–1.2), urine protein-to-creatinine ratio 19.4, albumin 1, and eGFR 30 (baseline ~87). Initial management included aggressive diuresis, immunosuppression, and steroids, which were poorly tolerated. The patient had multiple recurrent hospitalizations.
Outpatient treatment with mycophenolic acid and prednisone taper failed to improve proteinuria or kidney function. Rituximab was discontinued due to diarrhea. Tacrolimus, despite therapeutic levels, was ineffective and not tolerated.
Given concurrent psoriatic arthritis, Upadacitinib 15 mg daily was initiated with mycophenolic acid, while other immunosuppressive agents were discontinued.
After five months, he demonstrated resolution of edema without diuretics, return of kidney function to baseline, and reduction in proteinuria from ~20 g/day to <700 mg/day.
Discussion
This case highlights the importance of alternative therapies in refractory nephrotic syndrome. Mycophenolic acid, prednisone, and other treatments, including Rituximab and tacrolimus, were ineffective or not tolerated.
Given concurrent psoriatic arthritis, Upadacitinib was initiated, resulting in a marked reduction in proteinuria and recovery of kidney function. As a JAK inhibitor, it may reduce inflammation and immune-mediated injury in glomerular disease. While evidence is limited, this case suggests potential efficacy in treatment-resistant membranous nephropathy. Its oral administration and tolerability make it a promising alternative. Further studies are needed to confirm safety and long-term outcomes.