Proliferative Glomerulonephritis with Monoclonal IgG Deposits and Refractory Ascites: Successful Treatment with Rituximab and Cell-free and Concentrated Ascites Reinfusion Therapy

Proliferative glomerulonephritis with monoclonal immunoglobulin deposits and atypical pathological findings treated with corticosteroid and rituximab

A 16-year-old girl with fever that appeared after taking the second COVID-19 vaccine presented to the clinic with a serum creatinine of 0.89 mg/dL and C-reactive protein of 6.9 mg/dL. She had proteinuria and microscopic hematuria, with slowly worsening kidney function. Her kidney biopsy showed fibrocellular crescents in seven of nine glomeruli that were observed under light microscopy. Another glomerulus showed endocapillary hypercellularity and mesangial cell proliferation. Electron-dense deposits were significant in the mesangial area, with monoclonal IgG1-κ and C3 deposition by immunofluorescence. The patient was diagnosed with proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) and atypical pathological finding of diffuse crescent formation. The treatment regimen for PGNMID has not yet been established, and the appropriate duration of treatment is unknown. In our case, considering that rituximab acts by binding to CD20 on the surface of B cells through its crystallizable fragment, it was administered in addition to prednisolone, which successfully decreased the proteinuria over time.

Cell-free and concentrated ascites reinfusion therapy for refractory massive cardiac ascites in an adult with single ventricle haemodynamics: a case report

Background

Cardiac ascites is a classical finding of right-sided heart failure, mainly caused by tricuspid valve disease and constrictive pericarditis. Refractory cardiac ascites, defined as ascites that is uncontrollable with any medication, including conventional diuretics and selective vasopressin V2 receptor antagonists, is a rare but challenging entity. Although cell-free and concentrated ascites reinfusion therapy (CART) is a therapeutic option for refractory ascites in patients with liver cirrhosis and malignancy, its efficacy in cardiac ascites has never been reported. We herein report a case of CART for refractory cardiac ascites in a patient with complex adult congenital heart disease (ACHD).

Case summary

A 43-year-old Japanese female with a history of ACHD involving single ventricle haemodynamics presented with refractory massive cardiac ascites due to progressive heart failure. Because conventional therapy using diuretics could not control her cardiac ascites, abdominal paracentesis was frequently required, resulting in hypoproteinaemia. Therefore, CART was initiated once per month in addition to conventional therapies, which enabled the prevention of hypoproteinaemia and further hospitalizations except to undergo CART. In addition, it helped improve her quality of life without any complications for 6 years until she died from cardiogenic cerebral infarction at the age of 49 years.

Discussion

This case demonstrated that CART can be safely performed in patients with complex ACHD and refractory cardiac ascites due to advanced heart failure. Thus, CART may improve refractory cardiac ascites as effectively as massive ascites caused by liver cirrhosis and malignancy and lead to an improvement in the patients' quality of life.