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Abstract: A 71-year-old man came to our hospital due to proteinuria combined with bilateral lower extremity edema seen in an outside hospital with poor results after medication. After completing relevant examinations, the preliminary diagnosis was primary membranous nephropathy, which is a common glomerular disease in clinical practice. According to his own situation, the patient was given rituximab injection. After drug treatment, the 24-hour urine protein quantification was significantly reduced and the blood albumin level recovered, and no clear side effects appeared at present.
[Basic information] Female, 71 years old
Disease Type】Primary membranous nephropathy
Hospital】Chinese People’s Liberation Army General Hospital
Date of Consultation】June 2021
Treatment plan】Intravenous injection (rituximab injection)
Treatment period】Hospitalization for 15 days, treatment maintained for 1 month, follow-up for 1 year
Treatment effect] Urine protein decreased significantly, and the disease gradually recovered
I. Initial consultation
The patient was a 71-year-old female, admitted to the hospital with proteinuria for 5 years and aggravated for 10 days. The patient was admitted with 24-hour urine protein of 4.08g and blood albumin of 25.3g/L. Other indicators were not abnormal, and she was admitted with “primary membranous nephropathy”. The patient was admitted to the hospital with “primary membranous nephropathy” as an outpatient. The patient had a renal biopsy (as shown below), which suggested hepatitis B-related membranous nephropathy. Since the patient did not have a history of hepatitis B, the results of the hepatitis B virus check showed a negative titer, and the PLA2R antibody was 205 IU/L, suggesting a high possibility of primary membranous nephropathy.
II. Treatment history
The treatment of membranous nephropathy includes hormone plus compound cyclophosphamide tablet, hormone plus cyclosporine soft capsule or tacrolimus capsule and rituximab injection for treatment. After confirming that the patient was suffering from primary membranous nephropathy, we felt that it was more appropriate to treat the patient with rituximab injection, so after the patient agreed, we gave the patient rituximab injection intravenously, and at the same time, we paid attention to the patient’s medication.
III. Treatment effect
The patient was treated with rituximab injection for 2 times, and after 1 month, the 24-hour urine protein quantification decreased from 4.08g to 2.455g on rechecking, and no abnormal symptoms and no significant side effects were observed during the treatment period. It is suggested that rituximab injection therapy may be a safe and effective treatment for elderly patients with membranous nephropathy. In conclusion, the patient was treated with medication for a total of 1 month and followed up for 1 year, during which the urine protein was significantly reduced and the condition gradually recovered with good therapeutic effect.
IV. Precautions
We are glad that the patient’s condition is under control. In addition, Rituximab Injection is not recommended to inject New Crown vaccine within six months because of its strong effect on humoral immunity. The most common side effect of rituximab injection is infection, so patients need to be reminded to pay attention to their own protection in daily life and avoid strain and cold.
Although patients do not have a history of hepatitis B, they have been diagnosed with hepatitis B-associated nephritis before after all, and they should also pay attention to the risk of hepatitis B infection or outbreak after this application of rituximab injection. It is recommended that outpatient review be conducted about 1 month after discharge, and every 1-3 months thereafter, mainly for urine routine, 24-hour urine protein quantification, blood albumin, blood creatinine, urea nitrogen, and the five tests of hepatitis B.
V. Personal insight
Because the diagnosis of hepatitis B-associated membranous nephropathy is not fully mature at present, and immunofluorescence staining of kidney tissue has certain limitations. This patient was found to be positive for PLA2R antibody, considering the possibility of primary membranous nephropathy. Combined with the fact that the patient did not have hepatitis B infection and the titer of hepatitis B virus was not high, the patient was finally determined to use rituximab injection, and it was found that the 24-hour urine protein quantification of the patient was significantly reduced after the use of the drug, and no clear side effects were observed, which proved that the treatment was effective.