A case of resistant Membranous Nephropathy with venous thrombosis treated with Rituximab presenting with a relapse Response to a second course of Rituximab

A 54 year old gentleman with no previous co-morbidities, with nephrotic syndrome, normal renal function complicated by deep vein thrombosis (DVT) in lower limbs with renal biopsy showing Membranous nephropathy was treated with Steroid and cyclophosphamide and later with Tacrolimus and steroids with no response in proteinuria and worsening renal function. His investigation revealed a protein of 3 and no active urine sediments and a 24 hr urinary protein of 14.3gmday, serum albumin of 2.0gmdl, hypercholesterolemia and serum creatinine was 1.9 mgdl. In view of poor response to Endoxan and worsening renal function to prednisolone and Tacrolimus, function he was advised for Rituximab .He was given Rituximab 500 mg per dose IV as an infusion for a total of four weekly doses and the follow up showed a good response with no symptoms and a urine analysis negative for protein and 24 hr urine protein of 505 mgday serum creatinine of 1.3 mgdl and the serum albumin of 4.1 gmdl, normal fasting lipid profile. After duration of two and half years in remission there was an increase in proteinuria to 5.6 gmday. He was given second course of Rituximab of three doses at 375 mg1.73 m2 per dose was given at weekly intervals. There were no adverse events during the infusion. After the second course of the Rituximab he improved symptomatically and with a reduction in 24 hr urine protein to 875 mgday and serum creatinine came down to 1.13mgdl. Conclusion A third of MN patients relentlessly progress to end stage renal disease and in this subset of patients rituximab has shown good promise in achieving remissions for prolonged intervals. Some of these cases, which subsequently relapse, can be treated with a second course of Rituximab successfully with no apparent side effects attributable to rituximab. There was a sustained remission and improvement in the GFR.