Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Allied Health Professionals’ Corner
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guideline
Guidelines
Image in Nephrology
Images in Nephrology
In-depth Review
Letter to Editor
Letter to the Editor
Letter to the Editor – Authors’ reply
Letters to Editor
Literature Review
Nephrology in India
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Allied Health Professionals’ Corner
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guideline
Guidelines
Image in Nephrology
Images in Nephrology
In-depth Review
Letter to Editor
Letter to the Editor
Letter to the Editor – Authors’ reply
Letters to Editor
Literature Review
Nephrology in India
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
View/Download PDF

Translate this page into:

Letter to the Editor
34 (
5
); 543-544
doi:
10.25259/IJN_40_2024

Membranous Nephropathy in a Treatment Naïve Patient of Rheumatoid Arthritis

Department of Internal Medicine, Military Hospital, Yol Cantt, Yol
Department of Internal Medicine, Armed Forces Medical College, Wanowrie, Pune, India
Department of Pathology, Armed Forces Medical College, Wanowrie, Pune, India.

Corresponding author: Rahil Arora, Department of Internal Medicine, Armed Forces Medical College, Wanowrie, Pune, India. E-mail: rahilarora1992@gmail.com

Licence
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

How to cite this article: Kumar S, Singh SK, Arora R, Kashif AW. Membranous Nephropathy in a Treatment Naïve Patient of Rheumatoid Arthritis. Indian J Nephrol. 2024;34:543-4. doi: 10.25259/IJN_40_2024

Dear Editor,

A 45-year-old woman presented with a one-month history of generalized body swelling Over the preceding month, she had gained 8 kg in weight, experienced reduced urine output, and reported easy fatigability. The patient also disclosed a two-year history of inflammatory polyarthritis affecting small joints in her hands and wrists, with no prior treatment. Clinically, she was afebrile, with normal vitals and her weight was noted to be 92 kg.

Evaluation revealed normocytic normochromic anemia (hemoglobin 9.3 g/dL), low serum albumin (1.2 g/dL), elevated serum cholesterol (333 mg/dL), hypertriglyceridemia (311 mg/dL), serum creatinine within normal limits (1.0 mg/dL), and an estimated glomerular filtration rate (eGFR) of 71 ml/min/1.73 m2. Urine analysis showed proteinuria (3+ on dipstick, 8 g/day on the 24-hour collection). Chest X-ray displayed blunting of bilateral costophrenic angles. While an ultrasound of the kidneys indicated normal size, her renal biopsy confirmed membranous nephropathy (MN).

Notably, the patient’s anti-cyclic citrullinated peptide antibody (Anti-CCP Ab) was highly positive (>500 U/ml), leading to a definite diagnosis of rheumatoid arthritis (RA) based on the 2010 ACR/EULAR criteria. Management involved diuretics, parenteral albumin, ACE inhibitors, steroids, anticoagulants, and septran prophylaxis. A percutaneous renal biopsy [Figure 1] confirmed MN, anti-PLA2R antibody was negative, and subsequent treatment with the anti-CD20 monoclonal antibody Rituximab was initiated. Conventional disease-modifying antirheumatic drugs (DMARDs) such as Methotrexate and Hydroxychloroquine were prescribed for RA.

(a and b) show thickening and stiffening of the glomerular capillary loop (400x, PAS and 400x JSM). (c) shows in addition to the thickened loops, there were pockets of lymphomononuclear inflammatory cell infiltrate in the cortical parenchyma and chronic mild inflammation (400x, PAS). (d) Direct immunofluorescence showed coarse granular deposits for anti sera specific against IgG (3+), Kappa (3+), Lambda (3+), C3 (1+) in the sub epithelial aspect of glomerular capillary loop. Rest of the panel IgA, IgM, C1q was negative, PAS: periodic acid schiff.
Figure 1:
(a and b) show thickening and stiffening of the glomerular capillary loop (400x, PAS and 400x JSM). (c) shows in addition to the thickened loops, there were pockets of lymphomononuclear inflammatory cell infiltrate in the cortical parenchyma and chronic mild inflammation (400x, PAS). (d) Direct immunofluorescence showed coarse granular deposits for anti sera specific against IgG (3+), Kappa (3+), Lambda (3+), C3 (1+) in the sub epithelial aspect of glomerular capillary loop. Rest of the panel IgA, IgM, C1q was negative, PAS: periodic acid schiff.

The patient responded well to the treatment (Rituximab and Methotrexate, Hydroxychloroquine), experiencing resolution of anasarca and albuminuria. Ongoing follow-up revealed sustained remission for both MN and RA.

MN is a significant cause of nephrotic syndrome in adults, comprising about 30% of cases, with 80% being primary (pMN) and 20% secondary (sMN).1 While the patient’s history and workup excluded causes of pMN, sMN, the positive response to RA treatment indicated a rare case of MN secondary to RA.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Conflicts of interest

There are no conflicts of interest.

Reference

  1. . Primary membranous nephropathy. Clin J Am Soc Nephrol. 2017;12:983-97.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]

Fulltext Views
531

PDF downloads
1,025
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections