Repository Corticotropin in Treating De-Novo C3 Glomerulonephritis Post-Transplantation

Abstract

Introduction: De-novo C3 glomerulonephritis (C3GN) post-transplant is uncommon. Although eculizumab has been used successfully in several cases, the response is heterogeneous and treatment strategies remain undefined. The use of repository corticotropin in C3GN has not been described in the literature. Case Report: A 48-year-old African American male with kidney transplantation secondary to presumed diabetic nephropathy presented six years post-transplant with lower extremity edema and nephrotic range proteinuria. His urine protein to creatinine ratio (UPCR) was 8.2 g/g. Renal allograft biopsy confirmed the diagnosis of C3GN. He was treated with eculizumab (Solaris®) 900 mg IV once weekly for four weeks and repository corticotropin (H.P. Acthar® gel) 80 units SQ twice weekly for six months with a near-complete resolution of proteinuria within three months of the treatment. The patient presented again six months after completing the therapy with a recurrence of proteinuria, which peaked at 11.6 g/g of UPCR. Repeat kidney allograft biopsy was consistent with C3GN. He was started on repository corticotropin 80 units SQ twice weekly, which resulted in a reduction of proteinuria to >50% within two months of therapy. When eculizumab 900 mg IV weekly for four weeks was added with repository corticotropin, the proteinuria resolved within ten weeks of treatment. The patient was maintained on monotherapy of repository corticotropin and has been in complete remission of proteinuria for more than a year until his last follow-up. Conclusion: In conclusion, this is the first case report describing the role of repository corticotropin as an effective therapy in reducing proteinuria and maintaining patients with C3GN in proteinuria remission.