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      Immunoadsorption: A New Strategy to Induce Remission in Membranous Lupus Nephritis

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          Abstract

          We report the case of an 11-year-old previously healthy girl who presented for microscopic hematuria and nephrotic proteinuria with normal renal function, which persisted after 6 months of steroids, angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers, hydroxychloroquine, mycophenolic acid and a low-salt diet. A serum investigation suggested lupus nephritis and a renal biopsy, performed 2 weeks after the first proteinuria detection, revealed membranous lupus nephritis. We decided to perform ten sessions of daily immunoadsorption. Proteinuria decreased significantly over these ten sessions from 8 to 0.12 g/l. After the tenth immunoadsorption session, the patient received the first rituximab (RTX) infusion leading to complete B-cell depletion. The patient was maintained on ACEi associated with mycophenolic acid and hydroxychloroquine. Three RTX reinjections were performed when CD19-positive cells reappeared in peripheral blood. Despite complete B-cell recovery and positive anti-dsDNA-Ab, the patient remained in complete remission 18 months after the initial diagnosis with negative proteinuria and a normal renal function.

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          Most cited references 20

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          The KDIGO practice guideline on glomerulonephritis: reading between the (guide)lines--application to the individual patient.

          The KDIGO guideline for glomerulonephritis is designed to assist health-care providers in treating patients with glomerular diseases. A guideline is not a set of rules but is intended to allow the practitioner to make an informed decision based on the available evidence. Due to its general nature and the variability of strength of the available studies, it is often difficult to directly apply a guideline to the care of an individual patient. This commonly relates to the limited generalizability of the evidence, i.e., does not cover every clinical scenario. To underscore this point, we have introduced within the context of the glomerulonephritis guideline cases with specific features to illustrate the constant need for clinical judgment. These vignettes are intended to demonstrate how the best treatment plans should be individualized and take into account patient preference and clinical acumen, as well as the best available evidence.
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            PLA2R autoantibodies and PLA2R glomerular deposits in membranous nephropathy.

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              Antenatal membranous glomerulonephritis due to anti-neutral endopeptidase antibodies.

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                Author and article information

                Journal
                CRU
                CND
                10.1159/issn.2296-9705
                Case Reports in Nephrology and Dialysis
                S. Karger AG
                2296-9705
                2014
                January – April 2014
                19 March 2014
                : 4
                : 1
                : 37-41
                Affiliations
                aDepartment of Pediatric Nephrology, APHP, DHU i2B Inflammation-Immunopathology-Biotherapy, Armand-Trousseau Hospital, bUniversity Pierre and Marie Curie, and cDepartment of Pathology, Tenon Hospital, APHP, Paris, France
                Author notes
                *Tim Ulinski, MD, PhD, Department of Pediatric Nephrology, APHP, DHU i2B Inflammation-Immunopathology-Biotherapy, Armand-Trousseau Hospital, APHP, 26, Avenue du Docteur Arnold Netter, FR-75012 Paris (France), E-Mail tim.ulinski@trs.aphp.fr
                Article
                361014 PMC4000301 Case Rep Nephrol Urol 2014;4:37-41
                10.1159/000361014
                PMC4000301
                24803916
                © 2014 S. Karger AG, Basel

                Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) ( http://www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 1, Pages: 5
                Categories
                Published: March 2014

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