#3508 A case of membranous nephropathy that reached remission with SGLT2 inhibitor alone

Abstract Case Presentation A 70-year-old woman was presented with proteinuria and lower leg edema. She was being treated for diabetes, dyslipidemia and coronary spastic angina, and her HbA1c was in the 6% range, indicating good blood glucose control. There were no abnormalities in the urinalysis, but proteinuria had been noted for three months prior to admission, and she was also presenting with hypoalbuminemia (serum albumin: 3.3 g/dL), so she was admitted to hospital. The urine occult blood test was negative, and the urine protein-to-creatinine ratio was 4.45 g/g·Cre. Renal function was normal, with an eGFR of 83 mL/min/1.73 m2. A renal biopsy was performed, and the patient was diagnosed with membranous nephropathy (MN). Anti-PLA2R antibodies and anti-THSD7A antibody are absent. A chest and abdominal CT scan did not reveal any malignancies as the cause. Her systolic blood pressure was in the 90 mmHg range, and she was unable to tolerate treatment with Renin-angiotensin system (RAS) blockers. After starting treatment with dapagliflozin, her urine protein became negative after 2 months of treatment, and she has been able to maintain remission for over 2 years. Discussion MN is the most common cause of adult-onset nephrotic syndrome; even though up to one-third of the patients may reach spontaneous remission at any time during the course of follow-up, one-third may persist with nephrotic syndrome, half of which may finally develop end-stage kidney disease. According to the KDIGO guidelines, all patients with MN should receive supportive management with antiproteinuric measures including RAS blockers, optimal blood pressure control, dietary sodium restriction, and diuretic therapy as needed. RAS blockers are a cornerstone of supportive treatment in the management of MN, but they cannot be used if they are not tolerated. In recent years, sodium-glucose cotransporter 2 (SGLT2) inhibitors have emerged as a promising adjunctive therapy to RAS blockers in managing MN, and in this case, a good outcome was obtained with SGLT2 inhibitors alone. Conclusion Patients with primary MN should receive optimal supportive therapy centered on RAS inhibitors, but in cases where RAS inhibitors are not tolerated, SGLT2 inhibitors can be used as an alternative. Furthermore, we believe that they are also beneficial in terms of blood pressure and fluid management, and salt restriction.