People who turned it around

a 35-year-old woman undiagnosed chronic kidney disease; started dialysis in an emergency during severe preeclampsia in her second pregnancy

After 18 months on dialysis, she began a moderately restricted, supplemented, low-protein diet. The diet let her stop dialysis. A few months later she started a new pregnancy even with very low kidney function. She then stopped seeing her kidney and nutrition doctors because she worried they would talk her out of the pregnancy, so she managed the diet on her own. She delivered a healthy baby at term and was still off dialysis when the report was written.

“Following slow recovery of kidney function, after 18 months of dialysis she started a moderately restricted, supplemented, low-protein diet, which allowed her to discontinue dialysis.”

Researchers: Nava J · Moran S · Figueroa V · Salinas A · Lopez M · Urbina R · Gutierrez A · Lujan JL · Orozco A · Montufar R · Piccoli GB

a 69-year-old man stage 3 chronic kidney disease with type 2 diabetes, hypertension, hyperphosphataemia and borderline hyperkalaemia

He started a strict whole-foods, plant-based diet. He did not count calories or portions and was not told to exercise. He quickly cut his insulin by more than half. Over 4.5 months his eGFR rose from 45 to 74 mL/min and his microalbumin to creatinine ratio dropped from 414.3 to 26.8 mg/g. His phosphorus level returned to normal, and his weight, blood pressure and cholesterol also improved. The authors note that a creatinine-based GFR reading can be thrown off by large weight loss.

“His estimated glomerular filtration rate (eGFR) increased from 45 to 74 mL/min after 4.5 months on the diet and his microalbumin/creatinine ratio decreased from 414.3 to 26.8 mg/g.”

Researchers: Campbell TM · Liebman SE

a 32-year-old nulliparous woman stage 4 chronic kidney disease with hypertension, during pregnancy

She had stage 4 kidney disease and became pregnant. To protect the baby, doctors put her on intensive haemodialysis from week 11 to week 31 of the pregnancy, aiming for normal pre-dialysis urea levels. At the same time she tried a plant-based diet. The doctors think the diet helped lower her blood urea, and by the later part of the pregnancy she no longer needed dialysis. She had a normal pregnancy outcome. The authors say these pregnancies are still high risk.

“We hypothesise that her dietary changes assisted with urea reduction, enabling her to become dialysis independent.”

Researchers: Seed E · Gilbertson E

a G4P1 woman (pregnant, one prior birth) atypical anti-glomerular basement membrane (anti-GBM) disease that started during pregnancy at 13 weeks

Her doctors used several treatments at once. She had plasma exchange to clean the harmful antibodies out of her blood, high-dose methylprednisolone (a strong steroid), and hemodialysis. The pregnancy was ended as part of the plan. When the antibodies came back in her blood, she was given a drug called obinutuzumab. After this, she was able to stop dialysis. Two kidney biopsies taken over time showed the active damage dropping from 64.3% to 30.8% of the sampled tissue, which the report says is evidence the kidney was starting to repair.

“Multidisciplinary management, including plasma exchange, high-dose methylprednisolone, hemodialysis, pregnancy termination, and obinutuzumab for serologic recurrence, enabled discontinuation of dialysis and partial renal recovery with stable kidney function.”

Researchers: Zhuang J · Gu S · Qu Y · Zhang C · Kuang H · Cui Z · Tian X · Jiang H

a 19-year-old man Refractory immune complex-mediated membranoproliferative glomerulonephritis (IC-MPGN)

A 19-year-old man had immune complex membranoproliferative glomerulonephritis. He came in with heavy protein in his urine, blood in his urine, low blood albumin (20 g/L), and low complement (C3 as low as 0.06 g/L). A kidney biopsy confirmed the diagnosis. Steroids and tacrolimus did not control the disease, so his doctors started pegcetacoplan, a C3 blocker, at 1,080 mg injected under the skin twice a week. His urine protein-to-creatinine ratio fell to 751 mg/g, down 70 percent, and his 24-hour urine protein fell to 1,386 mg a day, down 83 percent. His blood albumin rose from 20 to 36 g/L and his creatinine stayed stable at 92 micromol/L. His complement returned to normal, with C3 rising from 0.06 to 1.27 g/L, and he was able to stop his blood pressure and immune-suppressing drugs. No side effects were seen.

“The urine protein-creatinine ratio (UPCR) decreased to 751 mg/g (-70% from baseline), and 24-h urinary protein excretion declined to 1,386 mg/day (-83%).”

Researchers: Al-Muhaiteeb A · Al Yousef A · Altaleb A

a 74-year-old woman IgA nephropathy with a membranoproliferative (MPGN) pattern associated with autoimmune hepatitis and liver cirrhosis

A 74-year-old woman had autoimmune hepatitis and liver cirrhosis, but her liver disease was in remission after past steroid treatment. She came in with heavy protein loss in her urine (nephrotic range) and swelling in her lower legs. A kidney biopsy showed IgA nephropathy with a membranoproliferative pattern, a type that usually has a poor outlook. Even so, corticosteroid treatment led to rapid and lasting remission of the protein in her urine.

“Despite the typically poor prognosis associated with MPGN patterns, corticosteroid therapy led to rapid and sustained remission of proteinuria.”

Researchers: Adachi H · Noishiki H · Ehara H · Tamagaki K · Sonomura K

a 66-year-old woman PLA2R-positive primary membranous nephropathy (stage III), refractory after anti-rituximab antibody-associated rituximab failure

A 66-year-old woman had membranous nephropathy that tested positive for the PLA2R antibody. She was treated with rituximab, but her body made antibodies against rituximab and the drug stopped working. Her B cells came back, the drug was undetectable in her blood, and her urine protein got worse. A kidney biopsy confirmed stage 3 membranous nephropathy. Her doctors then gave her obinutuzumab, another antibody that targets B cells. It fully cleared the B cells in her blood and reached a good blood level, and she reached both immune and clinical remission within 8.5 months, even though she still had the anti-rituximab antibodies.

“She was subsequently treated with the humanized type II anti-CD20 antibody obinutuzumab, which induced complete depletion of circulating B cells, achieved therapeutic serum concentration, follow by both immunological and clinical remission within 8.5 months, despite persistent ARA positivity.”

Researchers: Guo J · Zhong A · Wu D · Liu Y · Chen Y · Xu Y · Xu R · Wan Q

a 44-year-old man IgA nephropathy (Oxford M1,E0,S1,T1,C0) linked to adalimumab, in a man with seronegative rheumatoid arthritis

A 44-year-old man had seronegative rheumatoid arthritis. He took adalimumab starting in 2014, and it controlled his arthritis for five years. In 2019 he developed protein in his urine (1 gram a day), ongoing blood in his urine, and low complement levels. A kidney biopsy showed IgA nephropathy. His doctors suspected the adalimumab was linked to the kidney problem, so they stopped it. His urine protein dropped to 0.1 gram a day and his creatinine returned to normal. A later drug called tofacitinib did not control his arthritis well. In 2021 he started certolizumab, which controlled his arthritis and kept his kidney disease in remission at 0.2 gram of protein a day.

“Suspecting a temporal association with adalimumab, the medication was discontinued, resulting in a significant decrease in proteinuria (to 0.1 g/day) and normalization of serum creatinine.”

Researchers: Tüfekçi B · Kardaş RC · Öğüt B · Erden A

a 46-year-old woman Biopsy-confirmed IgA nephropathy with microscopic hematuria and nephritic-range proteinuria

She had already tried six months of high-dose prednisone with a RAAS blocker and an SGLT2 inhibitor, but it did not work and gave her strong steroid side effects. Doctors switched her to targeted-release budesonide, a steroid that acts mostly in the gut. Over six months her urine protein dropped from 2,536 mg a day to 66 mg a day, the blood in her urine went away, and her eGFR rose from 65 to 80. The steroid side effects did not come back.

“Over six months, proteinuria decreased from 2,536 mg/day to 66 mg/day, hematuria completely resolved, and estimated glomerular filtration rate improved from 65 to 80 mL/min/1.73 m².”

Researchers: Manrique-Pizarro PA · Cordero E

a 73-year-old woman IgA nephropathy with cellular crescents, in a patient with polycythemia vera carrying a JAK2 V617F mutation

Doctors avoided steroids at first because steroids could worsen her blood cancer. Instead they started a JAK inhibitor called ruxolitinib. Over the next year her urine protein went down and her serum creatinine held steady. Later she took a two-year tapering course of corticosteroids and reached clinical remission. The authors say this is the first reported case of IgA nephropathy improving after JAK inhibitor treatment.

“Over the following year, urinary protein levels decreased and serum creatinine stabilized, suggesting that JAK inhibition may have contributed to an improvement in IgAN activity.”

Researchers: Takahashi-Kobayashi M · Nishikii H · Shimizu T · Kaneko Y · Sakata-Yanagimoto M · Usui J

a 63-year-old man Overlap of PR3-ANCA-associated vasculitis and primary focal segmental glomerulosclerosis (FSGS)

He was given pulse methylprednisolone into the vein, then prednisone pills and rituximab to control the vasculitis. Because his nephrotic syndrome kept going, doctors added a calcineurin inhibitor, first cyclosporine and then tacrolimus, for the steroid-resistant FSGS. They also used renin-angiotensin system blockers, an SGLT2 inhibitor, and later a nonsteroidal mineralocorticoid blocker to lower protein in the urine. His protein loss started at 8.25 grams a day. He reached partial remission and his PR3 antibodies became undetectable.

“The patient eventually achieved partial remission with resolution of his nephrotic syndrome and undetectable PR3 titers.”

Researchers: Landsberg A · Marzolf DE · Walker SR · Cheema K · Harrison TG

a 65-year-old woman Membranous nephropathy with nephrotic-range proteinuria, driven by idiopathic multicentric Castleman disease (iMCD-NOS), alongside Sjögren's syndrome and severe neuropathy

She first got rituximab combined with cyclophosphamide and dexamethasone, but her nerve symptoms got worse. The anti-IL-6 medicine that guidelines prefer was too expensive for her to get. So doctors gave her rituximab on its own, one cycle at a time, for nine cycles over 24 months. By January 2024 her protein in the urine was gone, her inflammation markers were almost normal, and her nerves recovered.

“Single-agent rituximab was initiated and continued for nine cycles over 24 months, achieving clinical remission by January 2024 with near-normalization of inflammatory markers, resolution of proteinuria, and neurological recovery.”

Researchers: Wang S · Chen T · Liu S · Du Z · Kong Y · Yuan Y · Ding T · Wang Q

Case 1, a high-risk idiopathic membranous nephropathy patient High-risk idiopathic membranous nephropathy, confirmed by renal biopsy and anti-PLA2R antibody testing

He or she received Huaier Granules, an herbal extract product, together with renin-angiotensin system inhibitor drugs (RASi) as the base treatment. After more than a year, the anti-PLA2R antibody became negative and the urine protein, blood albumin, and kidney filtering rate all improved. The report does not give the exact lab numbers.

“Case 1 achieved complete clinical remission and Case 2 partial remission.”

Worth knowing: selling product, unverifiable numbers

Researchers: Zhao T · Liang H · Yang X · Xiao X

a 6-year-old boy Immunoglobulin A nephropathy (IgAN) alongside PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis)

He did not respond well to cimetidine, so at age 7 his doctors removed his tonsils (palatine tonsillectomy). No extra immune-suppressing drugs were needed. After the surgery his fever episodes stopped, his blood in the urine ceased, and a repeat biopsy showed the kidney tissue had improved a lot.

“Repeat kidney biopsy at 11 months postoperatively showed marked histological improvement, with resolution of mesangial hypercellularity and reduced endocapillary proliferation.”

Researchers: Hirano D · Joh K · Honma S · Sakaguchi R · Saito A · Hiwatari Y · Yoshizawa S · Shoji Y · Sakaguchi H · Umeda C · Miwa S · Ito A

a 48-year-old man Paraneoplastic membranous nephropathy (PLA2R/THSD7A/NELL-1 triple-negative) together with stage IV mantle cell lymphoma

He was treated for the lymphoma alone with R-CHOP and R-DHAP chemotherapy to start, then an autologous stem cell transplant, and extended rituximab maintenance. Treating the cancer alone brought the kidney disease into remission, with kidney function preserved.

“nephrotic syndrome resolved, with proteinuria decreasing from 7.38 to 0.29 g/24 hours and serum albumin improving from 26.2 to 35.5 g/L with preserved kidney function.”

Researchers: Lv D · Sun P · Li Y · Liu T · Ye F · Yu Y · Li T · Liu A

a 66-year-old woman Membranous nephropathy with impure nephrotic syndrome and positive anti-PLA2R antibodies, alongside a pulmonary adenocarcinoma

Her nephrotic syndrome did not go away after the lung cancer was surgically treated and the tumor went into remission. She reached remission only after she was given immunosuppressive therapy.

“Remission was only achieved after the use of immunosuppressive therapy.”

Researchers: Jerbi M · Riguen M · Bettaieb A · Khadhar M · Gaied H · Aoudia R · Hadded S · Goucha R

a 71-year-old female NSAID-induced secondary membranous nephropathy with acute kidney injury, from long-term unsupervised NSAID use for polymyalgia rheumatica

She reached clinical remission after she stopped the NSAID drug and was treated with intravenous methylprednisolone combined with rituximab. When she was accidentally given the NSAID again, the disease came back.

“The patient achieved clinical remission after NSAID discontinuation and treatment with intravenous methylprednisolone combined with rituximab, but disease relapse occurred after inadvertent NSAID re-exposure.”

Researchers: Li J · Zhang Q · Chen Z · Qiu Y · Liu Y

a 37-year-old Thai male Anti-PLA2R antibody-positive membranous nephropathy with nephrotic syndrome, plus a distal tubule problem that caused very low potassium

He responded well to prednisolone and oral cyclophosphamide. As the nephrotic syndrome went into remission, his low potassium got better at the same time.

“The patient responded well to prednisolone and oral cyclophosphamide.”

Researchers: Vongchaiudomchoke T · Cheunsuchon B · Wachiraphansakul N

a 28-year-old Arab man Class IV lupus nephritis from a rheumatoid arthritis and lupus overlap called Rhupus syndrome

He first took oral prednisolone, hydroxychloroquine, and mycophenolate mofetil, and improved. When he got worse and developed fluid around the lung (lupus pleuritis), his doctors gave him pulses of intravenous methylprednisolone and stronger oral treatment. He reached complete remission on a cyclosporine-based plan.

“Single Rhupus syndrome in a young man complicated by class IV lupus nephritis and pleural effusion: complete remission with cyclosporine-based therapy: a case report.”

Worth knowing: no baseline

Researchers: Fallouh N · Aldakak MA · Al Jabban Y · Ahmad R · Sahloul W · Darwish B

a pregnant woman (G4P1) atypical anti-glomerular basement membrane (anti-GBM) disease, an autoimmune kidney attack, which began at 13 weeks of pregnancy

Doctors used several treatments together: plasma exchange, high-dose methylprednisolone (a steroid), hemodialysis, ending the pregnancy, and obinutuzumab (a B-cell-clearing antibody) when the antibodies came back. Repeat kidney biopsies showed the active damaging lesions fell from 64.3% to 30.8%. She was able to stop dialysis and keep stable kidney function. The report also found antibodies against type IV collagen alpha1 and alpha3 chains and laminin-521.

“Serial kidney biopsies demonstrated a reduction in active necrotizing lesions from 64.3% to 30.8% following early intensive immunosuppression and pregnancy termination.”

Researchers: Zhuang J · Gu S · Qu Y · Zhang C · Kuang H · Cui Z · Tian X · Jiang H

a 20-year-old man anti-glomerular basement membrane (anti-GBM) disease, an autoimmune attack on the kidneys, which started after a dental infection and caused rapidly worsening kidney failure

He first got the standard treatment of plasmapheresis (filtering the blood), corticosteroids, and cyclophosphamide, but his kidney function kept getting worse. Doctors then added obinutuzumab, a monoclonal antibody that clears out B immune cells, given as a single 500 mg dose into a vein. His antibody levels cleared within 1 month. He got his kidney function partly back and was off dialysis by 3 months, settling into stable stage 3 chronic kidney disease at 5 months.

“Remarkably, the patient achieved partial renal recovery and was dialysis-independent by 3 months, with stable stage 3 chronic kidney disease at 5-month follow-up.”

Researchers: Xue C · Yang B · Hong X · Lu Y · Qian Y · Li X · Liu N · Wu J

a 34-year-old Chinese man (Case 1) Fabry disease, an inherited (X-linked) disorder from a GLA gene mutation (c.493G>T) that damages the kidneys; he had proteinuria and severe kidney impairment

He was given enzyme replacement therapy with agalsidase beta (brand name Fabrazyme, made by Sanofi) at 1 mg per kilogram of body weight every two weeks. He received this therapy for 21 months before having a kidney transplant at about age 32. The doctors say the kidney recovery was mainly due to the transplant, while the enzyme therapy helped control the disease throughout his body. His blood marker Lyso-Gb3 dropped 70.6%, from 93.33 to 27.38 ng/mL, and the protein in his urine resolved.

“His plasma Lyso-Gb3 decreased by 70.6% (93.33 to 27.38 ng/mL).”

Researchers: He Z · Wu Y · Yang H · Li Y · Xu L

two White men in their sixties with relapsed acute myeloid leukemia minimal change disease (nephrotic syndrome) as the first sign of AML relapse after a stem cell transplant

Both men had a kidney biopsy that confirmed minimal change disease. Steroids did not stop their kidneys from getting worse. Their kidney function only got better after doctors started treatment aimed at the leukemia itself, not more immune-suppressing drugs. One of the two men recovered enough to stop dialysis. The report says the key was controlling the underlying cancer.

“Corticosteroid therapy was ineffective in halting renal deterioration; renal function improved only after initiation of leukemia-directed therapy, with one patient achieving dialysis independence.”

Researchers: Saleem K · Kamat S · Khurram NA · Hendawy BS · Ito S · Amarapurkar P