Abstract: FR-PO0692
NELL-1 Membranous Nephropathy Associated with Alpha-Lipoic Acid Infusions
Session Information
- Glomerular Diseases: Membranous Nephropathy, FSGS, and Podocytopathies
October 23, 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
- Fatima, Amanah S., University of Michigan, Ann Arbor, Michigan, United States
- Lapedis, Cathryn Jane, University of Michigan, Ann Arbor, Michigan, United States
- Mariani, Laura H., University of Michigan, Ann Arbor, Michigan, United States
Introduction
The rising popularity of alpha-lipoic acid (ALA) infusions for their therapeutic potential in conditions such as diabetic neuropathy has underscored their recent ubiquity at wellness clinics across the United States. We present a case of NELL1 membranous nephropathy resulting from high-dose biweekly ALA infusions.
Case Description
A 53-year-old man with type 2 diabetes and Roux-en-Y gastric bypass complicated by pancreatic insufficiency resulting in malabsorption and neuropathy was receiving high-dose IV ALA infusions. He was admitted following surgical reduction of a hernia.
While inpatient, his exam showed lower extremity and scrotal edema. He was hospitalized one month prior due to anasarca (serum albumin 0.9 g/dL) that was treated with IV furosemide and albumin. Current labs showed hypoalbuminemia of 2.8 g/dL with a 24-hour urine protein of 6.8g; serum creatinine was stable at 0.9-1.1. Serology testing for autoimmune, malignant, and infectious causes was unremarkable.
After discharge, kidney biopsy confirmed phospholipase A2 receptor (PLA2R)-negative membranous nephropathy; mass spectrometry identified NELL1. The patient was instructed to stop the ALA infusions. One month later, 24-hour urine protein dropped to 3.7 g/dL. At the 3-month mark, it decreased further to 0.42 g/dL.
Discussion
NELL1 is the second most common autoantigen in membranous nephropathy and has been associated with thiol-based compounds, such as lipoic acid. Our case highlights the need to recognize this agent’s ability to cause nephrotic syndrome and ensure appropriate safety information is provided to patients. In cases where ALA is the suspected offending agent, prompt discontinuation may lead to remission without the need to initiate steroids.
Immunofluorescence shows granular capillary wall reactivity for IgG, C3, Kappa, and Lambda. PLA2R staining is negative.
(L) Rare craters and small spikes seen in the capillary loop on Jones silver stain. (R) Electron microscopy with E&C stage I-II findings, including segmental effacement of podocytes and sub-epithelial deposits with early spike formation.