In Vivo Dynamics of Immunoregulatory Lymphocyte Reconstitution: A Seven-year Longitudinal Study of Sustained Remission in Class IV Lupus Nephritis Following Rituximab Therapy.
Shau-Jie Hung, Jeng-Wei Lu, Yi-Jung Ho et al.
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Case in brief
A 20-year-old woman presented with edema, nephrotic proteinuria (8.1 g/day), hematuria, hypoalbuminemia, anemia, and acute kidney injury. Serology showed high ANA and anti-dsDNA antibody levels with low complement; renal biopsy demonstrated Class IV lupus nephritis with diffuse proliferative glomerulonephritis and a full-house immunofluorescence pattern. After treatment including intravenous methylprednisolone and rituximab, CD19-positive B cells fell from 46.83% to 0%, anti-dsDNA levels declined, and renal function improved. Over seven years, B cells repopulated to approximately 20% while clinical remission persisted, with stable renal function and no renal flare.
What made this case unusual
Peripheral CD19-positive B-cell repopulation occurred during sustained remission, showing a persistent dissociation between B-cell numbers and renal disease activity in this patient.
Diagnostic / clinical pearl
After rituximab for lupus nephritis, peripheral CD19-positive B-cell counts alone may not reflect renal disease activity; interpret them alongside clinical, renal, and serologic findings.
Why it matters
The longitudinal observations suggest that the quality of immune reconstitution may be more relevant to sustained remission than the absolute CD19-positive B-cell count, although this single case cannot establish that relationship.