Öz
Membranous nephropathy (MN) is a primary cause of nephrotic syndrome in adults, often linked to antibodies against M-type phospholipase A2 receptor (PLA2R). Immunosuppressive therapy, such as rituximab and calcineurin inhibitors, is utilized for high-risk patients. This case report discusses a 74-year-old female with anti-PLA2R-positive MN, whose treatment was delayed due to a false-positive hepatitis A virus (HAV)-IgM result. Despite asymptomatic presentation and normal liver function, concerns about potential viral reactivation complicated clinical decisions. After a month of monitoring, immunosuppressive treatment was initiated, and the patient’s proteinuria achieved remission. This case underscores the importance of thorough evaluation of serological results, especially in cases where viral markers could influence critical treatment decisions. The risk of delaying MN treatment must be balanced against the potential dangers of initiating therapy under uncertain viral infection status.
Anahtar Kelimeler
Membranous nephropathy (MN) Anti-PLA2R Hepatitis A virus (HAV) Immunosuppressive therapy
Etik Beyan
Ethical approval: In this case report, ethical committee approval was not required; therefore, it was not obtained.
Destekleyen Kurum
Funding: The authors received no specific funding for this work. Conflict of interest: The authors declare that they have no conflict of interest. Availability of data and material: The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Kaynakça
- 1. Couser, W. G. Primary membranous nephropathy. Clin. J. Am. Soc. Nephrol. 12, 983– 997 (2017).
- 2. Debiec, H. et al. Antenatal membranous glomerulonephritis due to anti-neutral endopeptidase antibodies. N. Engl. J. Med. 346, 2053–2060 (2002)
- 3. Beck, L. H. et al. M-type phospholipase A2 receptor as target antigen in idiopathic membranous nephropathy. N. Engl. J. Med. 361, 11–21 (2009).
- 4. Kidney Disease: Improving Global Outcomes (KDIGO) Glomerular Diseases Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int. 100, S1–S276 (2021)
- 5. van de Logt, A. E. et al. Immunological remission in PLA2R-antibody-associated membranous nephropathy: cyclophosphamide versus rituximab. Kidney Int. 93, 1016– 1017 (2018).
- 6. Lemon SM , Ott JJ , Van Damme P , Shouval D . Type A viral hepatitis: a summary and update on the molecular virology, epidemiology, pathogenesis and prevention. J Hepatol. 2017 Sep 5;68:167–84.
- 7. Bower WA , Nainan OV , Han X , Margolis HS . Duration of viremia in hepatitis A virus infection. J Infect Dis. 2000 Jul;182(1):12–7.
- 8. Cohen JI , Feinstone S , Purcell RH . Hepatitis A virus infection in a chimpanzee: duration of viremia and detection of virus in saliva and throat swabs. J Infect Dis. 1989 Nov;160(5):887–90.
- 9. Martin ST, Cardwell SM, Nailor MD, et al. Hepatitis B Reactivationand Rituximab: A New Boxed Warning and Considerations for Solid Organ Transplantation. Am J Transplant. 2014;14:788–96.
- 10. Sustained false-positive results for hepatitis A virus immunoglobulin M: A case report and literature review Youwen Tan and Li Chen
- 11. Tennant E , Post JJ . Production of false-positive immunoglobulin M antibodies to hepatitis A virus in autoimmune events. J Infect Dis. 2016 Jan 15;213(2):324–5.Centers for Disease Control and Prevention positive test results for acute hepatitis A virus infection among persons with no recent history of acute hepatitis—United States, 2002-2004. MMWR Morb Mortal Wkly Rep 2005; 54:453–6.
- 12. Landry ML. Immunoglobulin M for Acute Infection: True or False? Clin Vaccine Immunol. 2016 Jul;23(7):540–5.
- 13. Landry ML. Immunoglobulin M for Acute Infection: True or False? Clin Vaccine Immunol. 2016 Jul;23(7):540–5
Öz
Membranöz nefropati (MN), erişkinlerde nefrotik sendromun yaygın bir nedenidir ve çoğunlukla M-tipi fosfolipaz A2 reseptörüne (PLA2R) karşı gelişen antikorlarla ilişkilidir. Yüksek riskli MN vakalarında immünosupresif tedavi önerilmekte olup, tedavi öncesi viral enfeksiyonların değerlendirilmesi önemlidir. Hepatit A virüsü (HAV) enfeksiyonu, genellikle akut ve kendini sınırlayan hepatit ile ilişkilidir ve anti-HAV IgM pozitifliği aktif enfeksiyon göstergesi olarak kabul edilir. Ancak nadiren yanlış pozitif sonuçlar tedavi sürecini karmaşıklaştırabilir.
Bu çalışmada, anti-PLA2R pozitif MN tanısı konulan ve yanlış pozitif anti-HAV IgM sonucu nedeniyle tedavi süreci geciken 74 yaşındaki bir kadın hasta sunulmaktadır. Hasta, nefrotik düzeyde proteinüri ile başvurdu ve böbrek biyopsisi ile MN tanısı doğrulandı. Yüksek anti-PLA2R titresi nedeniyle immünosupresif tedavi planlandı ancak hepatit taramasında anti-HAV IgM pozitifliği saptandı. Hastanın karaciğer enzimleri normal ve hepatit semptomları olmamasına rağmen, tedavi ertelendi. Farklı merkezlerde yapılan testler pozitifliği doğruladı ancak bir aylık izlemde hepatit gelişmemesi üzerine yanlış pozitiflik düşünüldü. Rituksimab ve ardından kalsinörin inhibitörü tedavisi başlatıldı. Tedavi süresince hepatit bulgusu gözlenmedi ve hasta remisyona girdi. On sekiz aylık takipte remisyon devam etti ancak anti-HAV IgM pozitifliği sürdü.
Bu olgu, MN tedavisinde viral serolojilerin dikkatli değerlendirilmesi gerektiğini ve yanlış pozitif sonuçların tedavi kararlarını etkileyebileceğini göstermektedir.
Anahtar Kelimeler
Membranöz nefropati (MN) Anti-fosfolipaz A2 reseptörü (Anti-PLA2R) Hepatit A virüsü (HAV) İmmünsüpresif tedavi
Kaynakça
- 1. Couser, W. G. Primary membranous nephropathy. Clin. J. Am. Soc. Nephrol. 12, 983– 997 (2017).
- 2. Debiec, H. et al. Antenatal membranous glomerulonephritis due to anti-neutral endopeptidase antibodies. N. Engl. J. Med. 346, 2053–2060 (2002)
- 3. Beck, L. H. et al. M-type phospholipase A2 receptor as target antigen in idiopathic membranous nephropathy. N. Engl. J. Med. 361, 11–21 (2009).
- 4. Kidney Disease: Improving Global Outcomes (KDIGO) Glomerular Diseases Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int. 100, S1–S276 (2021)
- 5. van de Logt, A. E. et al. Immunological remission in PLA2R-antibody-associated membranous nephropathy: cyclophosphamide versus rituximab. Kidney Int. 93, 1016– 1017 (2018).
- 6. Lemon SM , Ott JJ , Van Damme P , Shouval D . Type A viral hepatitis: a summary and update on the molecular virology, epidemiology, pathogenesis and prevention. J Hepatol. 2017 Sep 5;68:167–84.
- 7. Bower WA , Nainan OV , Han X , Margolis HS . Duration of viremia in hepatitis A virus infection. J Infect Dis. 2000 Jul;182(1):12–7.
- 8. Cohen JI , Feinstone S , Purcell RH . Hepatitis A virus infection in a chimpanzee: duration of viremia and detection of virus in saliva and throat swabs. J Infect Dis. 1989 Nov;160(5):887–90.
- 9. Martin ST, Cardwell SM, Nailor MD, et al. Hepatitis B Reactivationand Rituximab: A New Boxed Warning and Considerations for Solid Organ Transplantation. Am J Transplant. 2014;14:788–96.
- 10. Sustained false-positive results for hepatitis A virus immunoglobulin M: A case report and literature review Youwen Tan and Li Chen
- 11. Tennant E , Post JJ . Production of false-positive immunoglobulin M antibodies to hepatitis A virus in autoimmune events. J Infect Dis. 2016 Jan 15;213(2):324–5.Centers for Disease Control and Prevention positive test results for acute hepatitis A virus infection among persons with no recent history of acute hepatitis—United States, 2002-2004. MMWR Morb Mortal Wkly Rep 2005; 54:453–6.
- 12. Landry ML. Immunoglobulin M for Acute Infection: True or False? Clin Vaccine Immunol. 2016 Jul;23(7):540–5.
- 13. Landry ML. Immunoglobulin M for Acute Infection: True or False? Clin Vaccine Immunol. 2016 Jul;23(7):540–5
Ayrıntılar
| Birincil Dil | İngilizce |
|---|---|
| Konular | Sağlık Hizmetleri ve Sistemleri (Diğer) |
| Bölüm | Olgu Sunumları |
| Yazarlar | |
| Yayımlanma Tarihi | 21 Haziran 2025 |
| Gönderilme Tarihi | 21 Mart 2025 |
| Kabul Tarihi | 16 Mayıs 2025 |
| Yayımlandığı Sayı | Yıl 2025Cilt: 47 Sayı: 2 |
