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Abstract: TH-PO947

The Cryo Menace

Session Information

Category: Trainee Case Report

  • 1202 Glomerular Diseases: Immunology and Inflammation

Authors

  • Kalipatnapu, Sri Mahathi Priyanka, Macneal Hospital, Berwyn, Illinois, United States
  • Chaturvedula, Chandra Kanth, Loyola University Medical Center, Maywood, Illinois, United States
  • Picken, Maria M., Loyola University Medical Center, Maywood, Illinois, United States
  • Schneider, Julia, Loyola University Medical Center, Maywood, Illinois, United States
Introduction

Membranoproliferative glomerulonephritis (MPGN) and cryoglobulinemia is a well-recognized complication of HCV infection. We present an interesting case of persistent cryoglobulinemia and MPGN despite sustained remission of hepatitis C treated with Harvoni (direct-acting antiviral).

Case Description

56 year old man with a history of Hepatitis C cirrhosis, previously treated with Harvoni, was referred for proteinuria and hematuria. Besides mildly elevated transaminases and indirect Bilirubin, his metabolic profile was unremarkable. Protein creatinine ratio was 2gm/gm. Hepatitis C PCR was undetectable. Serology showed low complement levels and normal values of HbA1c, ANA, Anti ds-DNA, ANCA, Anti-PLA2R abs, and hepatitis B and C antibody. Serum and urine, protein electrophoresis with immunofixation, failed to reveal any monoclonal proteins. Interestingly, cryoglobulins were detected in the serum and a renal biopsy demonstrated membranoproliferative glomerulonephritis with abundant, non-organized, predominantly subendothelial deposits (Fig A)

Discussion

MPGN is a pattern of glomerular injury that is characterized by mesangial hypercellularity, endocapillary proliferation, and double-contour formation along the glomerular capillary walls associated with cryoglobulinemia and Hepatitis C infection. Treatment with direct-acting antivirals (DAA) has curative sustained viral response (SVR), which has been shown to demonstrate cryoglobulinemic quiescence. Our case is unique given the persistence of circulating cryoglobulins and continued glomerular injury, despite SVR. Case of vasculitis and DAH in a patient with Hepatitis C treated with Harvoni was previously reported. This probably suggests that these antibodies propagate disease activity independent of HCV RNA load. Treatment with immunosuppression may be warranted, if there is nephrotic range proteinuria, a reduced estimated glomerular filtration, and/or severe histologic changes such as crescents on renal biopsy.

Fig A