Dr Cynthia Chhoa1, Dr Samantha Carija1, Dr Carolyn Orr2, Dr Rajalingam Sinniah3, Dr Revathy Manickavasagar1
1Department of Nephrology, Royal Perth Hospital, Perth, Australia, 2Department of Neurology, Royal Perth Hospital, Perth, Australia 3Department of Histopathology, Royal Perth Hospital, Perth, Australia
Biography:
Bio to come
Background:
B cell depleting therapy with rituximab, a chimeric CD20 monoclonal antibody, is established treatment for membranous nephropathy (MN) at risk of progression. Ocrelizumab is a humanised B cell depleting antibody approved for the treatment of multiple sclerosis (MS) with only one published case report describing use in anti-PLA2R positive MN.
Case Report:
A 65-year-old man presented with nephrotic syndrome and preserved creatinine (albumin 21g/L, ACR 756mg/mmol). Past medical history included acute disseminated encephalomyelitis 15 years prior, with hyperintensities at T5/6 and supratentorial white matter demonstrated on MRI. Serum anti-PLA2R was negative. Kidney biopsy confirmed membranous glomerulonephritis with negative anti-PLA2R staining. Secondary screen including malignancy screen was negative. He had ongoing heavy proteinuria despite 6 months of maximal supportive anti-proteinuric therapy. 6 months after MN diagnosis, he developed right sided paraesthesia and diagnosis of MS was made based on MRI demonstrating new hyperintensity at C3/C4. He was treated with pulse intravenous methylprednisolone and ocrelizumab 300 mg IV six-monthly (x 4). Following this, nephrotic syndrome and proteinuria significantly improved, with ACR 7.8mg/mmol, albumin 41g/L and stabilisation of neurological symptoms.
Conclusion:
We have described a case of anti-PLA2R negative MN associated with MS and treated successfully with ocrelizumab. The patient’s MN may have been associated with (1) an unidentified circulating auto-antibody, (2) secondary to MS, which is not commonly described, or (3) the two conditions may have a yet to be identified common pathogenesis. Ocrelizumab successfully treated both conditions simultaneously.