Abstract: PUB159
NELL-1-Associated Membranous Nephropathy in a Patient with Prostate (and Later Pancreatic) Cancer
Session Information
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Authors
- Khan, Saila Azam, New York University Grossman School of Medicine, New York, New York, United States
- Bailey, Ronelle, New York University Grossman School of Medicine, New York, New York, United States
- Drakakis, James, New York University Grossman School of Medicine, New York, New York, United States
Introduction
Patients with membranous nephropathy (MN) have an increased risk of malignancy compared to the general population, with the target antigen previously unknown. Antigen discovery revealed that nerve epidermal growth factor-like 1 (NELL1) immune complexes were uniquely present within biopsy tissue in MN. 33% of patients with NELL1 had malignancy, more than those that were PLA2R- and THSD7A- positive. In fact, this was the most common antigen in 111 cases of malignancy associated MN. Our case illustrates this heightened association and highlights the importance of ongoing thorough investigation for coexistant cancers.
Case Description
79 year old male with history of diabetes, hypertension, and past hospitalization for acute pancreatitis, presented with nephrotic syndrome. 4 years prior, he was diagnosed with prostate cancer, having undergone radical prostatectomy. Subsequently underwent radiation and androgen deprivation therapy (ADT) until 2 months before current presentation. Noted to have serum albumin 1.8 g/dL with 24 hour urine protein of 11 grams. That course complicated by two neurologic events felt to be consistent with transient ischemic attacks (perhaps hypercoagulable). Follow up PET CT showed metastases to left external iliac and thoracic notes, for which he resumed Leuprolide injections as well as Enzalutamide. Over the course of the next year, proteinuria improved to 200-300 mg/g with serum albumin 3.7 g/dL, as the PSA became undetectable. Later, workup for new jaundice revealed a pancreatic head mass, diagnosed as adenocarcinoma with liver metastases.
Discussion
For a case of MN to be malignancy associated, it must fulfill certain clinical criteria which can be difficult to establish. I.e., the malignancy and glomerular disease must occur within a similar time frame (generally 2 years) and undergo essentially simultaneous remissions. In one series, 9/12 patients successfully treated for malignancy showed complete or partial remission. Furthermore, relapse of the glomerular disease ought to occur congruent to cancer recurrence. Due to the association of NELL1 associated MN with malignancy, one should undergo thorough screenings. Further investigation need determine the mechanism linking antibody production and development of related MN. Our patient illustrates not only these principles, but also the potential for occult malignancy, present even as MN remission has been achieved.