ASN's Mission

To create a world without kidney diseases, the ASN Alliance for Kidney Health elevates care by educating and informing, driving breakthroughs and innovation, and advocating for policies that create transformative changes in kidney medicine throughout the world.

learn more

Contact ASN

1401 H St, NW, Ste 900, Washington, DC 20005

email@asn-online.org

202-640-4660

The Latest on X

Kidney Week

Abstract: SA-PO879

When You Close a Door, a Window Opens: A Case of Dupilumab-Induced Autoimmune Glomerulonephritis

Session Information

Category: Glomerular Diseases

  • 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics

Authors

  • Alanzi, Meshaal, Temple University, Philadelphia, Pennsylvania, United States
  • Gillespie, Avrum, Temple University, Philadelphia, Pennsylvania, United States
  • Mani, Kishore Kumar, Temple University, Philadelphia, Pennsylvania, United States
  • Boyle, Suzanne, Temple University, Philadelphia, Pennsylvania, United States
  • Koul, Sheetal, Temple University, Philadelphia, Pennsylvania, United States
Introduction

Dupilumab, a monoclonal antibody that blocks IL-4 and 13, is indicated for atopic dermatitis management. Eosinophilic granulomatosis with polyangiitis (EGP) has been reported with dupilumab use. We report a case of AKI from lupus-like glomerulonephritis following dupilumab, suggesting that blocking IL-4 and 13 may be linked to autoimmunity.

Case Description

A 61-year-old man with a history of an orthotopic liver transplant for HCV-related cirrhosis five years prior and non-proteinuric CKD (baseline creatinine 2.3 mg/dl) was admitted for generalized fatigue, mild abdominal pain, nausea, and poor appetite. Serum creatinine was 8 mg/dl.
Four months before, he started Dupilumab for resistant atopic dermatitis. Further testing revealed normocytic anemia with Hb of 6.5 g/dL and thrombocytopenia 103 K/mm3. Urinalysis showed hematuria; urine protein to creatinine ratio 4216 mg/gram. Complement C3/C4 normal, ANA, anti-ds DNA, and rheumatoid factor negative. c-ANCA titer was 1:320 (negative for anti-PR-3 and MPO).
An ANCA-mediated GN was initially suspected. However, a kidney biopsy revealed a membranoproliferative glomerulonephritis with cellular crescents and a diffuse tubulointerstitial inflammatory infiltrate with "full house" staining on immunofluorescence, consistent with lupus-like nephritis. The patient was managed with steroids (500 mg methylprednisolone for three days, then 1 mg/kg with taper). Ultimately, he needed regular hemodialysis.

Discussion

In this case, Dupilumab was the most likely cause of this “full-house” ANCA-positive nephritis. Dupilumab has also been associated with EGP. The potential mechanism is that blocking IL4 increases autoimmunity.
IL-4 is considered an immunoregulatory cytokine with pleiotropic effects on antibody production, inflammation, and T-cell responses. It is suggested that IL-4 has a protective role against autoimmunity as it suppresses T-cell activity and tissue inflammation. In one mouse strain, the pathogenic autoantibody subclasses (IgG21 and IgG3) were suppressed by IL-4. Thus, mice with increased IL-4 had low levels of IgG3 and IgG2a subclasses of anti-DNA antibodies with high IgG1 levels, which is considered protective against lupus-like nephritis development. Consequently, suppressing IL-4 might lead to increased autoantibody subclasses that deposit in the kidney, inducing inflammation.