Abstract: TH-PO0524
Renal Recovery in Dialysis-Dependent Crescentic IgA Vasculitis: Abbreviated Cyclophosphamide and Rituximab-Based Induction in an Older Patient
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
Authors
- Krieger, Adam, Tulane University School of Medicine, New Orleans, Louisiana, United States
- Pittappilly, Matthew, Tulane University School of Medicine, New Orleans, Louisiana, United States
Introduction
IgA vasculitis (IgAV) is uncommon in elderly patients and carries a disproportionately poor renal prognosis when presenting with RPGN and dialysis dependence—a clinical scenario where recovery is rare and ESRD risk is high. Optimal induction immunosuppression remains debated; most severe crescentic cases receive prolonged cyclophosphamide (CYC) courses, while evidence supporting rituximab (RTX) is limited to small cohorts and case series.
Case Description
A 69-year-old male with a history of recent viral gastroenteritis presented with purpuric rash, severe polyarthralgia, dependent edema, and gross hematuria. Creatinine rose from <1.0 to 6.16 mg/dL within five days and BUN peaked at 143 mg/dL necessitating intermittent hemodialysis. Complement levels were normal; ANCA was negative. Skin biopsy confirmed leukocytoclastic vasculitis with IgA, IgG, and IgM deposition. Renal biopsy demonstrated IgAV nephritis (Oxford: M1, E1, S0, T0, C1)—active crescentic and endocapillary inflammation without chronic tubular atrophy or segmental sclerosis. Induction consisted of pulse methylprednisolone and a single IV CYC dose. He was subsequently transitioned to outpatient RTX and achieved dialysis independence before discharge. At three months, creatinine was 1.3 mg/dL and urine protein-creatinine ratio fell from 2.4 to 1.0 g/day.
Discussion
This case illustrates a clinicopathologic mismatch in elderly IgAV: severe dialysis-dependent AKI driven by active crescentic and endocapillary injury (E1, C1) in the absence of chronic irreversible damage (S0, T0). This histologic profile likely explains the unexpectedly favorable outcome. Critically, crescentic injury is not inherently irreversible; early identification and aggressive treatment can yield substantial renal recovery even in elderly patients. This patient's striking improvement following abbreviated CYC exposure and RTX transition suggests prolonged alkylating agent courses may not be absolute prerequisites in selected patients with severe IgAV nephritis. In a population where dialysis-dependent crescentic IgAV is historically associated with poor renal survival, this case reinforces that prompt aggressive immunosuppression can yield durable recovery and contributes to the emerging, though still limited, literature supporting B-cell depletion in severe IgA-mediated disease.