Membranous Nephropathy that First Presented in Pregnancy

Aoshima, Yumie; Iyoda, Masayuki; Nakazawa, Ai; Yamaguchi, Yutaka; Kuroki, Aki; Shibata, Takanori; Akizawa, Tadao

doi:10.2169/internalmedicine.52.0645

Cited by 13 publications

(9 citation statements)

References 19 publications

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“…Pregnant patients with high-grade proteinuria are at increased risk for placentofetal complications including intrauterine growth restriction, preterm delivery and fetal demise as evidenced by our case and existing literature 2 3. Also, our patient had hypertension, which is an independent risk factor for such complications.…”

Section: Descriptionsupporting

confidence: 61%

Course of membranous nephropathy during multiple gestations

et al. 2016

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DESCRIPTIONThe physiological adaptations in pregnancy can unmask underlying occult proteinuric renal disease. However, the effect of multiple pregnancies on the course of the disease is variable. We report the clinical course of a case of idiopathic membranous nephropathy through multiple pregnancies.A 25-year-old Hispanic woman was referred to our institution for worsening generalised swelling of the body, uncontrolled hypertension and 21 g/day of proteinuria at 34 weeks' gestation during her third pregnancy. There were no stigmata suggestive of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome. She was previously seen at our institution 5 years ago during her 1st pregnancy when 13 g/day of proteinuria was recorded at 25 weeks of gestation. At that time, she was treated with oral steroids and delivery was induced at 35 weeks due to intrauterine growth restriction. Placental biopsy revealed focal, tightly adherent blood clot, consistent with possible abruption. Renal biopsy performed in the postpartum period was consistent with membranous nephropathy (figure 1).She was treated with ACE inhibitors (ACEI) and at 3-month follow-up, she was asymptomatic, without oedema and urine protein-creatinine ratio (UPCR) had decreased to 7 g/g. She was lost to follow-up for 5 years until this recent admission. In the interim, she apparently had a second successful pregnancy but no data was available. During current pregnancy, delivery was induced at 34 weeks and the placental biopsy showed that it was critically small for gestational age and had focal intervillous fibrin deposition together with focal calcifications in the areas of more significant ischaemia (figure 2). Serology for antinuclear antibody, anti-double-stranded DNA, antiphospholipid antibody, viral hepatitis and rapid plasma regain were negative. Serum complements were within normal limits. During both the pregnancies, she had hypertension with average blood pressures in the range of 140-150/80-90 mm Hg, which is higher than expected for a normal pregnancy but within acceptable range for patients with preexisting chronic hypertension. At 1-month postpartum, UPCR was 1.8 g/g, without any treatment. Interestingly, her serum creatinine ranged between 0.6 and 0.9 mg/dL during this 5-year period. The patient was once again lost to follow-up. Learning points▸ Although there is physiological increase in proteinuria during pregnancy, the presence of nephrotic range proteinuria with or without hypertension in any trimester is always pathological and may be associated with underlying renal disease and a poor prognosis.

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Section: Descriptionsupporting

confidence: 61%

Course of membranous nephropathy during multiple gestations

et al. 2016

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“…Although there were only a few reports on MN in pregnant women, the response to immunosuppressive agents was reported to be rapid in all cases. In one case, a marked decrease of proteinuria was seen as early as 2 months after immunosuppressive agents use (15), and the time to achieve complete remission was 6 months in another case (16). However, the response was not rapid in patients with THSD7A-related MN.…”

Section: Discussionmentioning

confidence: 94%

“…However, they did not distinguish between idiopathic and secondary MN. Two cases of idiopathic MN that first developed during pregnancy have been documented (15,16). PLA2R and THSD7A have been recently identified as target antigens for idiopathic MN (2, 3).…”

Section: Discussionmentioning

confidence: 99%

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Membranous Nephropathy with an Enhanced Granular Expression of Thrombospondin Type-1 Domain-containing 7A in a Pregnant Woman

et al. 2016

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A 30-year-old woman with proteinuria first noted at 26 weeks of gestation was admitted to undergo further evaluation. A renal biopsy revealed membranous nephropathy (MN). There was no evidence of any secondary MN. Prednisolone was initiated 6 months after delivery. Four months later, her urine protein became negative. Enhanced granular staining for thrombospondin type-1 domain-containing 7A (THSD7A) in the glomeruli was retrospectively detected in a biopsy specimen. A literature review revealed that 60% of cases of THSD7A-related MN occurred in women of childbearing age. Therefore, THSD7A-related MN should be considered in female patients presenting with idiopathic MN in childbearing age.

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“…Nephrotic proteinuria presenting in the first half of pregnancy is suggestive of a primary kidney disease, rather than pre-eclampsia [1]. Diagnosing and treating pregnant women with active glomerular disease is often difficult [7][8][9]. However, the presence of nephrotic range proteinuria with or without hypertension in the first trimester is pathological and may be associated with underlying primary or secondary renal insult (e.g., systemic lupus erythematosus), in any case ending in poor prognosis.…”

Section: Discussionmentioning

confidence: 99%

Successful foetal outcome in a patient with primary membranous nephropathy and circulating anti-phospholipid antibodies: A case report

Farber

2018

OAJ Clin Case Rep

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There is little information about pregnancy outcomes in patients with active membranous nephropathy (MN), especially those with circulating autoantibodies to M-type phospholipase A2 receptor (PLA2R), the major autoantigen in primary MN. Membranous glomerulonephritis (MGN) represents an immunologically mediated disease characterized by deposition of immune complexes in the glomerular subepithelial space, frequently associated with circulating M-type phospholipase A2 receptor. Nephrotic syndrome (massive proteinuria and hypoalbuminemia) at diagnosis predicts poor prognosis. Pregnancy with active MGN is high risk for foetal loss, intrauterine growth restriction, and pre-eclampsia, and may worsen maternal renal function, especially with the presence of antiphospholipid antibody syndrome (APLA).We report a 23-year-old gravida in her first pregnancy, suffering from MGN and severe nephrotic syndrome, complicated by APLA syndrome. The patient was treated with enoxaparin, aspirin azathioprine, and Prednisone for a short time, in addition to furosemide and albumin intravenously. She was delivered at 30 weeks due to deteriorating maternal and foetal conditions.A successful neonatal and maternal outcome was achieved in this case. The patient's history revealed thrombocytopenia and APLA syndrome and continues to be treated chronically with enoxaparin. Kidney biopsy performed after delivery showed membranous MGN stage II-III. Herein, we present a case of successful pregnancy and foetal outcome in a young woman with APLA syndrome and MN.

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Membranous Nephropathy that First Presented in Pregnancy

Cited by 13 publications

References 19 publications

Course of membranous nephropathy during multiple gestations

Course of membranous nephropathy during multiple gestations

Membranous Nephropathy with an Enhanced Granular Expression of Thrombospondin Type-1 Domain-containing 7A in a Pregnant Woman

Successful foetal outcome in a patient with primary membranous nephropathy and circulating anti-phospholipid antibodies: A case report

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