Successful entecavir plus prednisolone treatment for hepatitis B virus-associated membranoproliferative glomerulonephritis

Abstract

Rationale:Adult-onset hepatitis B virus-associated membranoproliferative glomerulonephritis (HBV-MPGN) is generally refractory, and an effective treatment for this condition has not been established. The indications for steroids in HBV-MPGN are an important clinical concern.Patient concerns:A 28-year-old woman with a chronic hepatitis B virus infection developed nephrotic syndrome in her second month of pregnancy, with urinary protein levels of 3 to 10 g/d that continued into her postpartum period. She was a carrier of HBV with HBeAg seroconversion. As her renal impairment could have been a result of pregnancy, we observed her for 10 months postpartum without any intervention. However, spontaneous remission after childbirth was not achieved and urine protein levels were sustained at 1 to 3 g/d. About 10 months after delivery, elevated serum liver enzyme levels were observed.Diagnosis:Biopsies showed MPGN, with deposition of hepatitis B antigen in the glomeruli, and chronic B-type hepatitis with a severity grade of A1F0. She was diagnosed with HBV-MPGN.Interventions:The patient was started on entecavir 0.5 mg/d in March 2008. Within 1 month, serum HBV DNA became undetectable; within 3 months, her alanine aminotransferase levels normalized. However, urinary protein excretion did not decrease to <2 g/d. On a second renal biopsy, performed 7 months after entecavir treatment, proliferative lesions of the glomeruli were observed; therefore, prednisolone was started at an initial dose of 30 mg/d.Outcomes:Her proteinuria improved immediately and prednisolone was tapered over 10 months. A third renal biopsy showed a remarkable resolution of HBV-MPGN, with a significant decrease in mesangial proliferation and immune complex deposition. HBV reactivation was not observed during the prednisolone treatment.Lessons:Additional prednisolone therapy in combination with antiviral therapy should be considered for refractory HBV-MPGN, with sufficient care taken regarding HBV reactivation.

Burden, Outcome, and Comorbidities of Extrahepatic Manifestations in Hepatitis B Virus Infections

“…Unlike HBV-membranous nephropathy, the treatment of HBV-associated membranoproliferative glomerulonephritis has not been well established; therefore, the efficacy of antiviral monotherapy for HBV-MPGN remains unknown [ 68 ]. One case report involved a 28-year-old postpartum woman who had renal biopsy confirmed MPGN type III and was initially started on entecavir at a dose of 0.5 mg once daily [ 68 ].…”

“…Unlike HBV-membranous nephropathy, the treatment of HBV-associated membranoproliferative glomerulonephritis has not been well established; therefore, the efficacy of antiviral monotherapy for HBV-MPGN remains unknown [ 68 ]. One case report involved a 28-year-old postpartum woman who had renal biopsy confirmed MPGN type III and was initially started on entecavir at a dose of 0.5 mg once daily [ 68 ]. Even though the HBV DNA became undetectable after 1 month of treatment, her kidney function did not improve as demonstrated by persistent proteinuria after 7 months of entecavir with a repeat biopsy showing evidence of active MPGN.…”

Hepatitis B Virus Infection and Extra-Hepatic Manifestations: A Systemic Disease

“…The treatment of HBV-associated GN relies on antiviral therapy. Successful treatment with analogs (entecavir), with or without prednisolone or immune-suppressive therapies, have been reported in small series and/or case reports (73)(74)(75). Finally, diagnosis and treatment in early stage benefit patients' renal outcomes.…”