Zhou Xu-Jie, Zhou Fu-De, Wang Su-Xia, Zhao Ming-Hui
Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, and Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China.
Medicine (Baltimore). 2018 Jun;97(25):e11184. doi: 10.1097/MD.0000000000011184.
As suggested by the 2012 KDIGO guidelines, persistent elevation of serum creatinine > 3.5 mg/dl (> 309 μmol/l) (or an estimated glomerular filtration rate < 30 ml/min per 1.73 m is one of contradictions for the use of immunosuppressive therapy in membranous nephropathy.
A 45-year-old man with membranous nephropathy negative for serum anti-phospholipase-A2-receptor antibody, showed no response to corticosteroids and cyclophosphamide. He progressed to chronic kidney disease stage 4 (CKD4) under tacrolimus and relapsed after withdrawal.
The patient received repeated renal biopsy, comfirming the diagnosis of membranous nephropathy with progressive glomerular and tubulointerstitial scarring.
He was treated with successfully four times with lose-dose (180 mg/m every 2-3 months) rituximab (RTX) depending on his B cell counts, aiming to remain at 0-5 cells/μl.
The patient was followed-up for almost 6 years. He achieved a partial remission at 11 months and a complete remission of the nephritic range of proteinuria at 34 months following infusion of RTX. RTX was well tolerated and the patient's renal function improved. He had no edema and his dosage of corticosteroids could be discontinued.
This case strongly suggested that rituximab has promising therapeutic significance, even in patients progressing to CKD4.
2012年KDIGO指南指出，血清肌酐持续升高>3.5mg/dl（>309μmol/l）（或估计肾小球滤过率<30ml/min/1.73m²）是膜性肾病使用免疫抑制治疗的矛盾情况之一。
一名45岁男性，血清抗磷脂酶A2受体抗体阴性的膜性肾病患者，对皮质类固醇和环磷酰胺无反应。在他克莫司治疗下进展为慢性肾脏病4期（CKD4），停药后复发。
患者接受了多次肾活检，确诊为膜性肾病伴进行性肾小球和肾小管间质瘢痕形成。
根据他的B细胞计数，每2 - 3个月低剂量（180mg/m²）利妥昔单抗（RTX）成功治疗4次，目标是将B细胞计数维持在0 - 5个/μl。
对患者进行了近6年的随访。输注RTX后11个月达到部分缓解，34个月时蛋白尿达到肾病范围的完全缓解。RTX耐受性良好，患者肾功能改善。他没有水肿，皮质类固醇剂量可以停用。
该病例强烈表明，即使对于进展至CKD4的患者，利妥昔单抗也具有有前景的治疗意义。
