CASE REPORT. Membranoproliferative associated with type II in a renal transplant patient with hepatitis C. Glomerulonefrite membranoproliferativa em. Disease definition. Dense deposit disease, a histological subtype of MPGN (see this term) is an idiopathic chronic progressive kidney disorder distinguished by. Glomerulonefrite membranoproliferativa. Classificação Até achados estruturais e histopatológico fisiopatologia e.
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Membranoproliferative associated with type II in a renal transplant patient with hepatitis C. The treatment of this entity is not consensual and represents a challenge to clinicians. We report a case of membranoproliferative glomerulonephritis glometulonefrite with type II in a year-old Caucasian male recipient of a deceased kidney transplant in His baseline serum creatinine SCr was 1. The laboratory tests revealed positive rheumatoid factor, hypocomplementaemia and a positive cryocrit with type II cryoglobulinaemia.
Antinuclear autoantibodies and anti-double stranded DNA antibodies were negative.
Despite the presence of anti-HCV antibodies, the viral load remained undetectable. The allograft biopsy showed lesions compatible with membranoproliferativewith staining in the immunofluorescence for granular IgM and C3 and no C4d.
He was treated with methylprednisolone pulses followed by oral prednisolone in association with rituximab. Two months after the last dose of rituximab, the SCr improved to 1. The patient was lost for follow-up. In our case, the treatment with rituximab resulted in a favourable outcome, although a longer follow-up period may be needed to evaluate the clinical response, since other studies reported high relapse rates. Cryoglobulinaemia; hepatitis C; kidney transplant; membranoproliferative glomerulonephritis; rituximab.
Os exames laboratoriais demonstraram: Os anticorpos antinuclear e anti-double stranded DNA foram negativos. Foi perdido o follow-up do doente. Crioglobulinemia; glomerulonefrite membranoproliferativa; hepatite C; rituximab; transplante renal.
Post-transplantation morbidity in renal transplant patients with hepatitis C virus HCV infection may be partially explained by the risk of de novo or recurrent HCV associated glomerulopathieswhich can lead to allograft dysfunction. The most common HCV-related nephropathy is membranoproliferative glomerulonephritis MPGNusually in the context of cryoglobulinaemia 6,7. Other glomerular diseases have also been reported, such as membranous nephropathy, minimal change disease, thrombotic microangiopathy, acute transplant glomerulopathy and chronic transplant glomerulopathies 1,4,5.
Treatment of this entity is a complex issue, nonconsensual and represents a challenge to clinicians. Rituximab, a human mouse chimeric monoclonal antibody directed against CD20 antigen on B lymphocytes, has recently proved to be effective on the treatment of this entity, however, the ideal dosage of this drug has not yet been defined. A year-old Caucasian male with a history of chronic kidney disease associated with HCV-related membranoproliferative MPGNhad a cadaveric renal transplant in The patient did not receive any previous antiviral therapy.
His baseline serum creatinine after transplantation was 1. He had a history of illicit drug abuse cocaine and heroin with methadone replacement therapy since His maintenance immunosuppressive treatment consisted of tacrolimus AdvagrafR 5.
Glomerulonefrite membranoproliferativa – Wikipedia, a enciclopedia libre
In Septemberhis SCr raised to 1. He was admitted in the hospital for further investigation. Renal function progressively worsened to a maximum of SCr of 2. An allograft biopsy was performed and showed lesions compatible with MPGN. C4d staining was negative. There were no other organ manifestations of. Two months after the last dose of rituximab, hypertension resolved, serum creatinine improved 1.
There were no infectious complications during the treatment with rituximab. After the last infusion, the patient restarted use of cocaine and was lost for follow-up. The management is critical and the main purpose is to improve long-term allograft survival.
The main goal of antiretroviral therapy before transplantation is to achieve sustained viral response, because the risk of hepatic and extra hepatic complications is reduced. The HCV is an independent risk factor for graft loss and proteinuria after transplantation 4,5, Higher HCV viral loads may result in more immune complexes and increased deposition of viral complexes in the kidney and a higher risk for HCV-related nephropathy 1,13 on the contrary, a sustained virological response serum HCV-RNA undetectable may reduce post-transplant recurrence of HCVas well as chronic allograft nephropathy 1,13, The treatment of this entity is a complex, nonconsensual issue and represents a challenge to clinicians.
Antiviral therapy is not routinely recommended in a renal transplant patient because of concerns regarding allograft rejection. According to KDIGO clinical practice guidelines oftreatment with interferon should be reserved to patients with fibrosing cholestatic hepatitis or life-threatening vasculitis Ribavirin monotherapy seems to improve liver enzymes level, but is not associated with beneficial effect on liver histology neither in virological clearance.
The IFN in combination with ribavirin is effective in two-thirds of patients after a minimum therapy of six months, but it is poorly tolerated and results in graft dysfunction in a significant number of patients 16, To date, there are no studies of this therapy in renal transplant and randomized controlled trials are needed Its use is not recommended in patients with renal transplant. The use of Rituximab the monoclonal anti-CD 20 antibody therapy in the setting of renal transplantation is multiple and includes desensitization and ABO-incompatible transplantation, treatment of humoral rejection, post-transplant lymphoproliferative disorders and recurrent or de novo glomerular diseases.
There have been several case reports and studies showing the effectiveness of Rituximab in the treatment of glomerular diseases, however, more randomized studies are needed 7,8,12,21, We describe a case of membranoproliferative associated with type II in a renal transplant patient with hepatitis C.
The association of this virus with mixed cryoglobulinaemia in our case may be explained by the presence of circulating anti-HCV antibodies, and the presence of HCV-RNA in the cryoprecipitate, suggesting that HCV exerted a pathogenic role in the formation of cryoglobulins.
Glomerulonefrite membranoproliferativa by Isabela Alcântara on Prezi
This diagnostic was surprising since the patient presented with sustained negative viral load, but there are other reported cases in the literature of HCV-related glomerulonephritis in patients with undetectable HCV-RNA In our case, the patient presented glomefulonefrite a severe renal disease that demanded a more aggressive approach.
The IgM autoantibody producing B lymphocytes appears to be depleted preferentially, which may explain the efficacy of this drug in this disease Rituximab seems to be as least as efficient as cyclophosphamide, is also better tolerated and, in contrast to cyclophosphamide, does not enhance HCV replication7.
For these reasons we decided to treat the patient with this drug. The treatment with Rituximab allowed an improvement in glomerulonefite function. However, a longer follow-up period post-therapy 12 months is needed to evaluate clinical response, since the relapse rate may be high.
The schedule and dosage recommended for this drug in renal transplant is not yet defined.
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