Membranous nephropathy associated with multiple sclerosis

Incidence, management, and outcomes of autoimmune nephropathies following alemtuzumab treatment in patients with multiple sclerosis

Background:

Autoimmune disorders including nephropathies have been reported more frequently in alemtuzumab-treated multiple sclerosis (MS) patients than in the general population.

Objective:

Describe instances of autoimmune nephropathy in alemtuzumab-treated MS patients.

Methods:

Cases were identified from safety monitoring within the alemtuzumab relapsing-remitting multiple sclerosis (RRMS) clinical development program (CDP) or post-marketing, or following off-label use.

Results:

As of 16 June 2017, 16 autoimmune nephropathies have occurred following alemtuzumab treatment for MS. The incidence of autoimmune nephropathies was 0.34% within the CDP (5/1485 patients). The five CDP cases (one of anti-glomerular basement membrane (anti-GBM) disease, two of membranous glomerulonephropathy, and two of serum anti-GBM antibody without typical anti-GBM disease) were identified early, responded to conventional therapy (where needed), and had favorable outcomes. Three of 11 cases outside the CDP occurred following off-label alemtuzumab use prior to approval for RRMS and were all anti-GBM disease. Diagnosis was delayed in one of these three cases and another did not receive appropriate treatment; all three cases resulted in end-stage renal failure. All anti-GBM disease cases with documented urinalysis demonstrated prior microscopic hematuria.

Conclusion:

Close monitoring of alemtuzumab-treated MS patients facilitates diagnosis and treatment early in the nephropathy course when preservation of renal function is more likely.

[Nephrotic syndrome in multiple sclerosis patients who had undergone long-term interferon β-1b therapy]

A 59-year-old man (case 1) with multiple sclerosis (MS) presented with shortness of breath and general fatigue. He had been treated using interferon β-1b (IFNβ-1b) since he was 51 years of age. Laboratory test results showed hypoproteinemia and hypoalbuminemia, proteinuria, and absence of hematuria. He was diagnosed with nephrotic syndrome, and the administration of IFNβ-1b was stopped. Percutaneous renal biopsy was performed, and the histology revealed membranous nephropathy. A 33-year-old woman (case 2) with MS, who had been treated using IFNβ-1b for 7 years, was diagnosed with proteinuria during a medical checkup. She was referred to a nephrologist and was found to have hypoalbuminemia and proteinuria. A diagnosis of nephrotic syndrome was made, and IFNβ-1b therapy was stopped. The patient underwent percutaneous renal biopsy, and the histology revealed membranous nephropathy. Both patients were treated using intravenous methylprednisolone followed by oral prednisolone. Case 1 was administered ciclosporin orally, and his clinical symptoms and laboratory test results improved at first, but his laboratory test results subsequently showed recurrence of proteinuria. Case 2 was administered mizoribine orally, resulting in improvement in clinical symptoms and laboratory test results. Case 2 showed relapse of multiple sclerosis, but the symptoms were mild and were alleviated after steroid therapy. IFNβ therapy has several complications including nephropathy. Previously, several cases of nephrotic syndrome associated with IFNβ within 2 years of therapy were reported, but drug-induced nephropathy could appear after several years of the therapy as our cases. We should pay attention to nephrotic syndrome under using long-term IFNβ.

Nephrotic syndrome in a multiple sclerosis patient treated with interferon beta 1a

BACKGROUND

Interferon beta has become standard therapy for reducing relapse frequency in relapsing/remitting Multiple Sclerosis (RRMS). Several different preparations are available including interferon beta 1a (Avonex, Rebif) and interferon beta 1b (Betaferon/Betaseron). For the most part these preparations have been considered safe. Recently there have been concerns relating to liver and now kidney toxicity.

CASE REPORT

We present a case of a 28-yr-old male who developed a severe case of nephrotic syndrome while being treated for relapsing/remitting Multiple Sclerosis (RRMS) with weekly injections of interferon beta 1a. SUBSEQUENT COURSE: The nephrosis resolved almost completely once the interferon was stopped and after immunosuppressive treatment. At its peak the daily protein loss was 35.82 g. Kidney biopsy demonstrated membranous glomerulonephritis.

DISCUSSION

Two other case reports of nephrotic syndrome have been reported in the literature. This latest (third) report suggests that the safety profile should be reexamined and at least raises the question of potential renal toxicity of interferons in MS.

Goodpasture's syndrome associated with multiple sclerosis

Multiple sclerosis (MS) has been reported to occur in association with other autoimmune diseases. Here we report the case of a woman with primary progressive MS who developed and died of Goodpasture's syndrome associated with anti-glomerular basement membrane antibodies. Of interest she had the human leukocyte antigen haplotype (DRB1*1501-DQA1*0102-DQB1*0602) most frequently associated with these two diseases; however, it is likely that other genes, particularly those involved with immunoregulation, also contributed to her susceptibility to these diseases. The association of MS and autoimmune renal disease may be more common than currently recognized.