# IgG4-related disease complicated by PLA2R-associated membranous nephropathy: A case report

## TL;DR

A rare case of IgG4-related disease combined with membranous nephropathy was successfully treated with a herbal medicine.

## Contribution

Reports a novel treatment of IgG4-related membranous nephropathy using Tripterygium wilfordii with no adverse effects.

## Key findings

- A 71-year-old patient with IgG4-related membranous nephropathy was treated successfully with low-dose hormones and Tripterygium wilfordii.
- The patient showed no adverse effects over an 8-year follow-up period.
- The case suggests that Tripterygium wilfordii could be a promising treatment for elderly patients with IgG4-related membranous nephropathy.

## Abstract

IgG4-related tubulointerstitial nephritis (IgG4-related TIN) is the prevalent clinical manifestation of IgG4-related diseases (IgG4-RD). However, there are limited cases of IgG4-RD occurring with membranous nephropathy (MN) in the absence of phospholipase A2 receptor (PLA2R). There have been no indications of treatment using Tripterygium wilfordii. This study reported a rare case of IgG4-RD with PLA2R-associated MN without any of the distinct IgG4-related TIN. The patient was treated effectively with T. wilfordii. A 71-year-old patient was admitted to the medical facility after presenting with a 1 month history of edema and 8 months of albuminuria. The renal biopsy tissue examination confirmed the presence of MN (phase II) in the absence of pathological manifestations of IgG4-related TIN. Immunohistochemistry identified PLA2R++ (granular capillaries). The serum PLA2R antibody titer was 1:180 (1:20). The patient met the diagnosis with IgG4-RD. Over 8 years of follow-up, the patient was effectively treated with low-dose hormones and T. wilfordii, without any adverse effects. This MN is considered a unique form of IgG4-RD, regardless of whether PLA2R antibodies are present or not. Research suggests that T. wilfordii could be a promising option for elderly people with IgG4-related MN, as it has been found to have fewer adverse effects.