Rituximab Therapy for Post-Liver Transplant Membranoprolifertive Glomerulonephritis Associated with Hepatitis C Viral Infection

Post-transplant membranoprolifertive glomerulonephritis(MPGN), due to hepatitis C virus, is a serious immunecomplex disease with potential for both kidney and liver loss.Treatment with corticosteroids and immunosuppressive canactivate viral infection and the use of interferon alpha caninduce acute rejection of the transplanted liver. In this casereport; a lady, with hepatitis C genotype 4, had developedsevere nephrotic syndrome with progressive renal failure dueto MBGN following liver transplant. Initially, she had receivedHarvoni (Ledipasvir/sofosbuvir) 90/400 mg daily for 12 weeks.Despite, clearance of hepatitis C viremia, she did not improve.Hence, Rituximab was started. Fortunately, her renal failureand nephrotic state improved without activation of hepatitis Cinfection or induction of rejection.

New protocols for treatment of class IV lupus nephritis with emphasis on rituximab as the sole maintenance therapy

Objective: A safe and effective treatment for lupus nephritis [LN]

Design: An 8-year prospective study

Setting: Hospital-based

Subjects: Three groups of patients with class IV LN; comparison of 2 new treatment-protocols for class IV LN with a retrospective group of patients who had received the standard treatment for LN

Intervention: The 2 treatment groups had received an induction phase of monthly intravenous Cyclophosphamide, Mycophenolate [MP] and Prednisone [P]. The maintenance phase in the first group was only MP and P, while patients in the second group had received only yearly Rituximab infusions

Main outcome measures: Morbidity and mortality

Results: Patients in the first group did not have significant relapses, yet had 10 episodes of infections during the maintenance phase. In the second group, there were five treatment failures, yet none had renal deterioration, infections or death. In the third group, seven relapses occurred during the induction period and three in the maintenance one. Moreover, complications included 1 death of disseminated sepsis, 12 cases of chronic renal failure, three kidney losses, 16 episodes of major infections, two cases of aseptic necrosis, two cases of gonadal failure, two cases of hemorrhagic cystitis and 2 cases of retinal deposits

Conclusions: Rituximab infusions, used once yearly, are effective and a safe maintenance therapy for most patients with LN after a short course of three anti-proliferative agents. In those who failed to respond, MP and P are more effective and safer than the standard protocol

Unstable angina as the first manifestation of a relapse in polyarteritis nodosa

Coronary involvement with polyarteritis nodosa [PAN] has been identified in post-mortem studies, yet rarely in clinical practice. We report a 38-year-old woman who presented with unstable angina for two days. She had a history of PAN and had received immunosuppressive therapy for two years, six years ago. Her initial ECG showed ST depression in most leads. Troponins were not elevated. Coronary arteriography revealed multiple aneurysms and stenotic lesions without obstruction. She also had anemia and progressive renal failure, indicating acute flare of PAN. She was treated with infusions of heparin, nitroglycerin, and oral Clopidogrel. Moreover, she received three daily infusions of 1 g solumedrol, followed by tapering dose of prednisone and three monthly 1 g Cyclophosphamide infusions, followed by Mycophenolate 1 g twice daily. She improved and remained stable for the next two years