Case Report

 

Authors: V. Lazarov, B. Deliyska

Clinic of Nephrology, University Hospital “Tsaritsa Yoanna” – Sofia

 

Address for Correspondence: V. Lazarov, Clinic of Nephrology, University Hospital “Tsaritsa Yoanna”, 8 Bialo More St., Sofia, e-mail: valentin.lazarov@yahoo.com

 

Keywords: nephrotic syndrome, superimposed crescentic glomerulonephritis

 

Abstract

We present a 42-year-old patient, with biopsically confirmed IgM – Mesangioproliferative glomerulonephritis, as an expression of Idiopathic nephrotic syndrome (INS) diagnosed in 1998. The pathogenic treatment had achieved a three-year remission. Due to a recurrence of the nephrotic syndrome, a control kidney biopsy was conducted in 2002, demonstrating no morphologic changes. Until 2004, a new round of pathogenic treatment was conducted, and again a remission was achieved until 2009. Then, without a clear reason, an increase of the serum creatinine up to 149 μmol/l was observed. Moreover, proteinuria of 3.9 g/24 h and erythrocyturia were found. A pulse of Cyclophosphamide and a treatment with Heparin were applied. Despite the treatment, the values of the creatinine continued rising and in April 2009 they reached 240 μmol/l. A third biopsy followed, which showed sclerotic changes both in the glomerular apparatus and in the interstitial tissue. Furthermore, the biopsy determined the presence of one global crescent out of 10 examined glomeruli which gave a reason to consider a more severe immunological conflict. A new Methylprednisolone pulse therapy was applied followed by a conventional dosage of Dehydrocortison on a scheme, and a 6-month treatment with Heparin 2х5000Е applied subcutaneously. As a result, the functioning of the kidneys improved substantially, the creatinine level decreased and remained in the range of 125 and 133 μmol/l.
It is important to underline that in the case of rapid deterioration of the kidney function and in the absence of contraindications, it is advisable to duly conduct a renal biopsy in order to determine the possibility of superimposed crescentic glomerulonephritis and/or necrotic vasculitis. The presence of ABM-antibodies and ANCA-antibodies should also be investigated. The results could facilitate a better adaptation of the pathogenic treatment.