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Glomerular diseases are the most common type of nephropathy related to HCV. The foremost common variety of HCV-associated glomerulopathy is immune-complex-mediated membranoproliferative glomerulonephritis (MPGN), which is linked to type II MC. It can also happen less commonly in the absence of cryoglobulinemia. Generally, patients with HCV infection have a greater chance of end-stage renal disease (ESRD) (4.3/1000 person-year), compared to patients without HCV infection (3.1/1000 person-year). treatment of HBV-related glomerular disease includes treatment of HCV it self and immunosuppression agents. Mycophenolate mofetil (MMF) is more selective than cyclophosphamide in inhibiting lymphocyte proliferation and functions. MMF may be a less toxic alternative to cyclophosphamide for the induction of remission in mixed cryoglobulinemic vasculitis.
A 57 years old male patient, with a known case of Hypertension not compliant with medications, a chronic smoker ( 30-pack-year), and a history of Hepatitis c infection was treated 10 years ago with antiviral therapy in the form of interferon and ribavirin for one year. He presented to the ED with a chief complaint of gaseous abdominal discomfort associated with bilateral lower limb edema extending up to the knee. there was no history of skin rash or arthralgia. Initial Labs showed severe hypoalbuminemia 10 mmol/L, hyperlipidemia, and severe nephrotic range Heavy proteinuria >6 g/day.
Labs during his first admission showed Cr 133 micromol/L, ANCA, ANA, dsDNA, and serum protein electrophoresis were negative, and both C3 and C4 were low. Hepatitis B screening was negative, and hepatitis C screening was indeterminant, but the PCR was negative and HCV RNA was not detected.
Urine analysis showed RBCs >100 cells. A kidney biopsy was performed and showed Membranoproliferative glomerulonephritis, Acute on chronic tubulointerstitial nephritis, Acute tubular necrosis, focal, Focal and segmental glomerulosclerosis with full house immunofluorescence. On discharge, the patient started prednisolone and steroid-sparing agents (Mycophenolate Mofetil 1 g BID). He came back with severe abdominal pain and fever, abdominal ultrasound showed significant ascites. The ascitic drain was performed and confirmed peritonitis although peritoneal fluid culture and blood and urine cultures were all negative. He was started on intravenous antibiotics for treatment of his spontaneous peritonitis.
MMF was stopped, and the patient was continued on prednisolone 30 mg daily and antibiotics. His MMF was resumed after discharge but he presented to the emergency room several times with fever and high inflammatory markers responding to antibiotics but all cultures remained negative. The possibility of him having seronegative lupus nephritis vs HCV MPGN picture, given his age and gender. Cryoglobulins were negative, but no evidence on the biopsy, and rheumatoid factor (RF) was high but no evidence on the biopsy. The decision on initiation of treatment HCV was entertained despite no evidence of the virus but it was agreed against it. He remained off immunosuppression treatment due to recurrent sepsis. The biopsy was discussed again with the pathologist and the electron microscopy pattern was not match with post-infectious GN.
HCV can cause a wide spectrum of glomerular diseases, but keeping in mind that the infection was treated 10 years ago and no virological evidence, the treatment of this immunocomplex disease in vie w of recurrent infections makes it difficult to establish immunosuppression treatment.