Kidney Week

Abstract: SA-PO0714

Not Hepatorenal Syndrome: Fibrillary Glomerulonephritis Despite Virologic Cure of Hepatitis C

Session Information

• Glomerular Diseases: Complement-Mediated Glomerulopathies and Infection-Related GN
  October 24, 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

• Alwan, Iktimal, AdventHealth Tampa, Tampa, Florida, United States

Iktimal Alwan, MD

• Abdalla, Mahmoud H., AdventHealth Tampa, Tampa, Florida, United States

Mahmoud H. Abdalla, MD

• Ramsakal, Asha, AdventHealth Tampa, Tampa, Florida, United States

Asha Ramsakal, DO

• Rothschild, Jason, AdventHealth Tampa, Tampa, Florida, United States

Jason Rothschild, MD

Introduction

Fibrillary glomerulonephritis (FGN) is a rare cause of glomerular disease, accounting for <1% of native kidney biopsies, and is classically associated with autoimmune disease, malignancy, and active hepatitis C virus (HCV) infection. Reports of FGN in patients with virologically suppressed HCV are uncommon. We present a rare case of rapidly progressive FGN occurring despite HCV viral clearance, initially masquerading as hepatorenal syndrome (HRS).

Case Description

A 68-year-old woman with treated HCV infection, cirrhosis, and type 2 diabetes presented with abdominal pain and lower extremity edema. Serum creatinine was 3.5 mg/dL from a previously normal baseline. CT imaging showed cirrhosis with large-volume ascites, and paracentesis ruled out spontaneous bacterial peritonitis. Fractional excretion of urea was 24%, supporting a prerenal process, and HRS was suspected. Diuretics were discontinued, and an intravenous albumin challenge was administered without renal improvement. A trial of terlipressin was discontinued due to hypoxia, and kidney function continued to decline.
Subsequent urine studies revealed nephrotic-range proteinuria with a protein creatinine ratio of 9.85 g/g, prompting kidney biopsy. The patient developed uremia and refractory volume overload requiring hemodialysis. Biopsy demonstrated FGN with lambda light-chain restriction and 70% interstitial fibrosis and tubular atrophy. Serologic evaluation showed positive HCV antibodies with undetectable HCV RNA; autoimmune serologies, cryoglobulins, serum free light-chain ratio, and serum protein electrophoresis were unremarkable. Given advanced fibrosis and poor predicted renal recovery, rituximab was deferred.

Discussion

This case illustrates a rare and diagnostically challenging presentation of FGN occurring after virologic cure of HCV, rapidly progressing to end-stage kidney disease. While HCV-associated glomerular disease is well recognized, FGN in the absence of active viremia is uncommon. The presence of cirrhosis led to initial suspicion of HRS, delaying recognition of glomerular disease. Given the poor renal prognosis of FGN, early consideration of kidney biopsy is essential. Rituximab has shown variable success, with better outcomes reported when initiated early before significant fibrosis develops.This case underscores the need for continued vigilance for glomerular disease in patients with HCV, even after viral clearance.