A Case of Lupus Nephritis Preceded by Minimal Change Disease and Membranous Glomerulonephritis

Abstract

Unusual clinical course Background:Lupus nephritis (LN) is the most common and serious complication of systemic lupus erythematosus (SLE). Minimal change disease (MCD) and primary membranous nephropathy (PMN) are the 2 most common causes of primary nephrotic syndrome. Our purpose in publishing this case report is to introduce an unusual clinical course and initial renal biopsy revealed MCD and then PMN in second renal biopsy. Subsequently, a third renal biopsy resulted in a final diagnosis of LN. To the best of our knowledge, this is the first such report. Case Report:The 31-year-old male patient was initially diagnosed with MCD after the first renal biopsy in 2004. He improved with initial management and had a complete remission for 9 years. After 9 years, the patient again presented with heavy proteinuria without systemic lupus erythematous finding and he was diagnosed with MN following the second renal biopsy. Seven years later, he again developed proteinuria alone with concurrent systemic symptoms of systemic lupus erythematosus, and a third biopsy was performed, leading to final diagnosis as LN. He was well managed with the methylprednisolone and cyclophosphamide (CTX) regimen, which improved renal function and spared the patient from continuous hemodialysis. Conclusions:In rare case, MCD may represent an early phase of lupus nephritis, which may subsequently develop into severe lupus nephritis.

Histological transition from minimal change disease to THSD7A-associated membranous nephropathy in a patient receiving long-term steroid treatment: A case report

“…To the best of our knowledge, there had only been one such case reported to date, in which first and second renal biopsy yielded the diagnosis of MCD and idiopathic MN, respectively, but third renal biopsy resulted in the final diagnosis of lupus nephritis. [ 7 ] In the reported case, causative antigen for idiopathic MN was not identified, and complement C1q deposition, which suggests the possibility of secondary MN, was observed. On the other hand, in our patient, C1q deposition was negative, and dominant IgG4 deposition by immunofluorescence IgG subclass staining was observed.…”

“…[14] Moreover, previous diagnosis of MCD and MN does not necessarily preclude the possibility of subsequent development of systemic lupus erythematosus, as reported earlier. [7] Predominant Th2 immune responses are supposed to play important roles in both MCD and MN. [3] Our patient presented elevated serum IgE level when he first developed MCD, although we did not evaluate the patient's other immune conditions, such as Th1/Th2 cytokines or thymus and activation-regulated chemokine.…”

“…[ 14 ] Moreover, previous diagnosis of MCD and MN does not necessarily preclude the possibility of subsequent development of systemic lupus erythematosus, as reported earlier. [ 7 ]…”

“…[4][5][6] However, whether some overlap exists between the 2 diseases is still unclear, and to the best of our knowledge, there is only 1 case reported that was initially diagnosed as MCD but subsequently developed into MN. [7] Here, we have reported a case in which the first renal biopsy diagnosed MCD, but the repeat renal biopsy, which was performed approximately 4 years later owing to the relapse of proteinuria, demonstrated the development of THSD7A-associated MN during long-term steroid treatment.…”

“…[ 4 – 6 ] However, whether some overlap exists between the 2 diseases is still unclear, and to the best of our knowledge, there is only 1 case reported that was initially diagnosed as MCD but subsequently developed into MN. [ 7 ]…”