V HERON1, M NICHOLSON1, S WILKINSON1, A YOUNG1, S GOVINDARAJULU1, S VENUTHURPALLI1
1Renal Service, Darling Downs Hospital And Health Service, Toowoomba, Australia
Background: As the use of anti–tumour necrosis factor-alpha (TNF-α) treatments for rheumatic and systemic autoimmune disorders increases, so does our understanding of their adverse effects. TNF-α blockade has been linked to the induction of autoimmunity, including autoimmune renal disorders. To our knowledge there have been no cases of anti-TNF-α therapy associated with anti-glomerular basement membrane (GBM) antibody disease reported.
Case report: A 63 year old male presented with anuric acute renal failure and was found to have a rapidly progressive glomerulonephritis secondary to anti-GBM antibody disease. This occurred in the setting of four years of adalimumab treatment for rheumatoid arthritis and normal baseline renal function. His presentation was preceded by a gastrointestinal illness and non-steroidal anti-inflammatory use. His anti-GBM titre was greater than 1000 chemiluminescent units (CU) at presentation. A renal biopsy revealed a crescentic necrotising glomerulonephritis with linear staining of IgG in the glomerular basement membrane. He was treated with pulse intravenous methylprednisolone and later changed to high dose prednisolone and cyclophosphamide. Four weeks of plasma exchange was completed. He remains dialysis dependent.
Conclusion: There is a known association between TNF-α blockade and autoimmune renal diseases. Given the rarity of anti-GBM antibody disease it is plausible that there could be an association between treatment with adalimumab and anti-GBM antibody disease and this may be the first case. It highlights the ongoing need for monitoring of renal function, urinary sediment and proteinuria in patients exposed to these novel therapies.
Vanessa Heron is an advanced trainee in nephrology currently working at Toowoomba Hospital, Queensland.