Tiopronin-induced membranous nephropathy: a case report

Figures & data

Table 1. Laboratory data at presentation.

Variable	Result	Reference range
Blood count
Leukocytes (10^9/L)	9.89	4.0–10.0
Erythrocytes (10^12/L)	4.77	4.0–5.5
Hemoglobin (g/dL)	154	120–160
Hematocrit (%)	45.8	42.0–49.0
Platelet count (10^9/L)	227	100–300
Serumchemistry
Total protein (g/L)	38	62–85
Albumin (g/L)	20	35–55
Globulin (g/L)	18	26–37
Total cholesterol (mmol/L)	11.78	3.59–5.17
Triglyceride (mmol/L)	1.69	0.57–1.71
Low-density lipoprotein (mmol/L)	8.44	1.33–3.30
Lactate dehydrogenase (U/L)	330	94–250
Glutamic pyruvic transaminase (U/L)	14	5–40
Glutamic oxaloacetic   transaminase (U/L)	34	8–40
Blood urea nitrogen (mmol/L)	5.3	1.7–8.3
Serum creatinine (μmol/L)	66	44–115
Fasting blood glucose (mmol/L)	4.3	3.6–5.8
HBV marker
Hepatitis B surface antigen	negative	negative
Hepatitis B surface antibody	negative	negative
Hepatitis B virus e antigen	negative	negative
Hepatitis B virus e antibody	negative	negative
Hepatitis B virus core antibody IgM	negative	negative
Hepatitis B virus core antibody IgG	negative	negative
Tumor marker
Alpha fetoprotein (ng/mL)	3.93	0–20
Carcinoembryonic antigen (ng/mL)	3.4	0–5
Carbodydrate antigen 19–9 (U/mL)	14.85	0–37
Carbodydrate antigen 242 (U/mL)	11.04	0–20
Prostate specific antigen (ng/mL)	0.446	0–4
Immunology
Immunoglobulin G (mg/dL)	283	751–1560
Immunoglobulin A (mg/dL)	176	82–453
Immunoglobulin M (mg/dL)	103	46–304
Immunoglobulin E (IU/mL)	35.7	<165
Complement C3 (mg/dL)	120	79–152
Complement C4 (mg/dL)	27.1	16–38
C-reactive protein (mg/dL)	0.25	<0.8
Circulating immune complexes (U/mL)	3.4	<13
Antinuclear antibodies	1:100	negative
Antibody against double-stranded DNA	negative	negative
Antibodies to extractable nuclear   antigens	negative	negative
Anti-neutrophil cytoplasmic   antibodies	negative	negative
Anti-glomerular basement   membranous antibody (RU/mL)	<20	<20
Anti-cardiolipin antibody	negative	negative
Anti-ribosomal P-protein antibody	weakly positive	negative
Serum immunofixation   electrophoresis	negative	negative
Urinary chemistry
Urinary protein (mg/24 h)	8620	0–150

Bold values in result column indicate the abnormal detected values beyond the reference range.

Figure 1. Renal biopsy findings. (A) Glomerular basement membranes appeared uniformly thickened without spikes (stained by periodic methenamine silver, original magnification ×400). (B) Tiny fuchsinophilic grains deposits along the outer aspect of the glomerular basement membranes (stained with Masson’s trichrome, original magnification ×400). (C) Immunoglobulin G subclasses IgG1 deposited along the glomerular capillary wall (stained immunohistochemically, original magnification ×400). (D) Immunoglobulin G subclasses IgG3 deposited along the glomerular capillary wall (stained immunohistochemically, original magnification ×400). (E) Effacement and fusion of epithelial cell foot processes (electron microscopy; original magnification ×8000). (F) Presence of subepithelial immune complex deposits (electron microscopy; original magnification ×10,000).

Figure 2. Clinical course after hospitalization. Time course of clinical indices after admission (A) serum total protein; (B) serum albumin; (C) proteinuria.

Table 2. Tiopronin-induced nephrotic syndrome cases reported in the literature.

Author	Publication year	Number of patient (n)	Pathologic diagnosis
Reveillaud et al.	1978	2	NR
Rizzoni et al.	1979	2	NR
Ambanelli et al.	1982	4	NR
Ferraccioli et al.	1986	6	MSPGN n = 1; MPGN n = 1; MN n = 4
Mordini et al.	1989	1	NR
Lindell et al.	1990	2	MN
Shibasaki et al.	1990	1	MN
Sany et al.	1990	3	NR
Koeger et al.	1993	4	NR
Asanuma et al.	1998	1	NR
Lecoules et al.	1999	1	MCD
Alvarez Navascués et al.	2001	1	NR
Tasic et al.	2011	1	NR

Note: MCD, minimal change disease; MN, membranous nephropathy; MPGN, membranousprolipherative glomerulonephritis; MSPGN, mesangioprolipherative glomerulonephritis; NR, no report.