Abstract: PUB182
A Rare Case of Primary Membranous Glomerulonephritis in HIV Successfully Treated with Adrenocorticotropin Injection Gel (Acthar)
Session Information
Category: Glomerular Diseases
- 1203 Glomerular Diseases: Clinical, Outcomes, and Trials
Authors
- Nazmul, Mohammed, Creighton University, Omaha, Nebraska, United States
- Alouch, Neil, Creighton University, Omaha, Nebraska, United States
Introduction
HIV patients are immunocompromised and treatment with steroids or cytotoxic agents for glomerulonephritis (GN) is challenging, There is paucity of data regarding Adrenocorticotropin injection like Acthar gel as an alternative immunosuppressive agent for Primary membranous GN in HIV patients.
Case Description
Our patient is a 55 years old African American lady with PMH of HTN,HIV on remission with Emtricitabine ,Tenofovir alafenamide , CKD with baseline creatinine 1.0-1.5 mg/dl. February 2018, patient’s urine showed protein: creatinine ratio 6.1 .Secondary work ups for proteinuria were negative. On renal biopsy, light /EM revealed membranous GN, minimal mesangial deposits favoring primary. Serum PLA2R antibody was 1:1120 (Normal <1.10), malignancy screening was negative. Patient started on Lisinopril then switched to Losartan to maxmum dose , proteinuria improved to 1.5 gram in February 2019 but increased again to 10.9 gram on November 2019,serum creatinine rose to 2.32 mg/dl . HIV specialist recommended against steroid, Acathr gel was started in April, 40 units s/q twice a week. Patient tolerated the medication well , HIV viral load undetectable, normal CD4 count and after 1 month proteinuria decreased to 4.9 gram, creatinine improved to 2.0 range and PLA2R antibody titer went down to 1:140.Acthar gel dose being uptitrated further accrding to patient's clinical response.
Discussion
This case study highlights the efficacy and tolerance of ACTH hormone therapy with RAAS blockade in HIV patient with primary membranous GN. Acthar gel may improve proteinuria due to its anti-inflammatory properties similar to steroid and can be considered as steroid sparing agents in difficult situations such as underlying HIV or other immunosuppressive diseases like HCV, HBV, malignancy.We conclude that, combination of RAAS blockade and Acthar gel can be a reasonable treatment regimen in complex case of primary membranous GN with coexistent HIV.