Case 22: Relapsing Membranous nephropathy in middle aged patient
To preserve patient privacy and for didactic purposes, case descriptions and pathology reports have been anonymized and partially fictionalized. The pathology images are representative images from a mixture of similar cases.
Rimda PeshinCase Presenter | Hofstra Northwell School of Medicine, Hempstead, NY, USA | No conflict of interest reported
Kenar D JhaveriNephrology Discussant | Hofstra Northwell School of Medicine, Hempstead, NY, USA | No conflict of interest reported
Patient is a 55-year-old woman with biopsy proven Membranous GN, a few years prior to current presentation, who underwent the modified Ponticelli regimen after a period of maximal antiproteinuric therapy and observation period for spontaneous remission. At that time, she had undergone age appropriate cancer screenings, all of which were negative. About 4 months into treatment she showed significant improvement with complete resolution of her severe edema, improvement of albumin to 3 g/dl (she was about 1.5 g/dl at the start of treatment) and proteinuria down to 2 grams from a peak of about 12 grams on spot urine. Unfortunately, she was lost to follow up and showed up again 6 months after treatment completion with a complete relapse. She was re-biopsied (see below).
Laboratory and other data: Serum PLA2R antibody negative.
Pathology images pending
Stage 3 membranous with 2 layers of immune complex deposits indicating a prior resolved episode and a more recent episode likely ongoing. Tissue PLA2R staining not available.
Questions posed & summary of key discussion points
1. What to treat the patient with next? Would you consider Rituximab? 2. Any additional cancer screening in light of her being PLA2R negative?
Author(s) of case summary:
Case summary pending
If you would like to be a contributing author for the creation of didactic materials and case summaries, please contact us at [email protected].