Membranous Nephropathy With Crescents in a Patient With Hashimoto’s Thyroiditis

Abstract

Membranous nephropathy is a common cause of nephrotic syndrome in adults. It usually occurs secondary to underlying disease processes such as autoimmune disorders, malignancy, infection, and drugs. The presentation of nephrotic syndrome with concomitant precipitous decline in renal function warrants investigation of a coexistent disorder.We report the case of a 30-year-old male who presented with symptoms and signs of hypothyroidism.A diagnosis of Hashimoto’s thyroiditis was contemplated based on the presence of high serum levels of antithyroglobulin and antithyroid peroxidase antibodies. Upon initiation of treatment with levothyroxine, patient symptomatology improved; however, the laboratory studies demonstrated continued elevated creatinine, hematuria, and proteinuria, which had not been addressed. Two months following treatment initiation, he had progressive deterioration in renal function and proteinuria. A renal biopsy revealed coexistent necrotizing and crescentic glomerulonephritis and membranous nephropathy.The final diagnosis was necrotizing, crescentic glomerulonephritis with superimposed membranous nephropathy likely secondary to Hashimoto’s thyrodiitis.Induction treatment with oral cyclophosphamide and prednisone was started.At the end of 6 months of treatment, there was improvement in renal function and proteinuria and maintenance treatment with azathioprine and low-dose prednisone was initiated. This case highlights the importance of precise and detailed evaluation of patients with autoimmune diseases such as Hashimoto’s thyroiditis particularly in the presence of active urine sediment. Proper evaluation and diagnosis of such patients has implications on the prognosis and response to treatment.

Phospholipase A2 Receptor Autoantibodies as a Novel Serological Biomarker for Autoimmune Thyroid Disease Associated Nephropathy

“…A renal biopsy revealed coexistent necrotizing and crescentic glomerulonephritis and membranous nephropathy. Induction treatment with oral cyclophosphamide and prednisone, at the end of 6 months of treatment, there was improvement in renal function and proteinuria (17), indicating that HT and membranous nephropath would have same pathogenesis. Anti-PLA2R-IgG has been confirmed as an autoantibody of IMN; therefore, in this study, a highly sensitive method for detecting anti-PLA2R-IgG in the serum was established with a sensitivity up to 0.07 mg/L.…”

Abnormalities of thyroid function tests in adult patients with nephrotic syndrome

“…Coexistence of autoimmune hypothyroidism has been described previously with various histological types of nephrotic syndrome, especially with membranous nephropathy. [14][15][16][17][18] In our study, four of 15 patients with membranous nephropathy had elevated anti-TPO antibodies.…”

Membranous Nephropathy and Anti-Podocytes Antibodies: Implications for the Diagnostic Workup and Disease Management

“…Secondary MN is associated with the presence of immune complexes possibly containing foreign antigens and is most often observed in children as well as in patients over the age of 60. It occurs in the context of a number of infections including viral hepatitis B (HBV), hepatitis C, and hepatitis E or syphilis [ 35 – 37 ], certain autoimmune diseases (systemic lupus erythematosus, antineutrophil, Hashimoto's thyroiditis, and Sjögren's syndrome) [ 32 , 33 , 38 ], hyper-IgG4 syndrome [ 39 ], malignancies (digestive tract, lungs, and breast) [ 40 ], and the use of medicinal products (heavy metal salts such as gold salts in particular, D-penicillamine and its derivatives, nonsteroidal anti-inflammatory drugs, and levamisole-adulterated cocaine [ 41 ]) [ 41 – 44 ]. It has also been described in association with diseases such as sarcoidosis, in both adults [ 45 – 49 ] and children [ 50 ], sickle-cell anaemia, and graft-versus-host disease [ 51 , 52 ].…”

“…In addition to their significant sensitivity, the specificity of anti-PLA2R1 antibodies for MN has been proposed close to 100% as they have not been detected in healthy subjects and in non-MN glomerular diseases [ 4 ]. However, even if their prevalence is much lower, the presence of anti-PLA2R1 antibodies in secondary MN (active sarcoidosis, lupus nephritis, and HBV infection) has been reported [ 32 , 33 , 38 – 52 ]. However, the occurrence of anti-PLA2R1 autoantibodies in membranous lupus nephritis is very rare and they have never been observed in non-MN lupus nephritis.…”