南予医学雑誌19巻
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赤松、他:Refractory NS achieving complete remission by LDL apheresis南予医誌 Vol.19 No. 1 2019-69-effusion.Urine examinations showed 20.4 g/dl and 18 g/day of proteinuria and 1.030 urinom-etry, and blood examination was as follows; WBC7600/μl,RBC312x104/μl,Hb9.1 g/dl,Plate41.9x104/μl,TP 3.9 g/dl,Alb 1.4 g/dl,BUN30.6 mg/dl,Cr2.14 mg/dl,T-Chol 161 mg/dl,HDL-Chol 29mg/dl,TG233 mg/dl,HbA1c 4.9%,CRP 21.76 mg/dl,BNP 407.2 pg/ml, and hepatic function and electrolytes were nor-mal.After admission, he was treated intensively as shown in Figure. He received albumin and furosemide to decrease edema, and then LDL-apheresis was performed twice using LA-15S (Kaneka Medical products, Tokyo), leading to complete remission. Recent laboratory data show; TP 7.5 g/dl, Alb 4.6 g/dl, BUN 16 mg/dl, Cr 0.74 mg/dl, T-Chol 176 mg/dl, TG 62 mg/dl, urine-Prot/Cr 0.54. Thereafter, he married and obtained a healthy baby in 4 years after dis-charge. At present 6 years after discharge, he has no proteinuria receiving decreased dose (5.0-7.5 mg/day) of prednisolone.DiscussionRefractory NS is resistant to various medi-cations. Our patient have received various toxic drugs including twice cyclophospha-mide treatments. At the time of admission, we hesitated an intensive treatment includ-ing high-dose CyA because of his anasarca which may be associated with long CyA treatment, and adopted LDL-apheresis after obtaining better condition. We speculate this LDL apheresis might have improved his steroid resistance. And then, despite various toxic drugs including cyclophospha-mide, he could obtain his healthy baby for-tunately. This case report is proceeded after conrming the patient’s permission.Several reports exhibited LDL-apheresis was effective to refractory NS (1,2). Yo-shizawa et al reported that, of 8 NS patients treated with LDL-apheresis including 3 min-imal change, 4 were in complete remission and one in incomplete remission (3). Muso reported that, in refractory NS, induction of lipoprotein synthesis in the liver due to hypoalbuminemia and loss of lipoproteinase into the urine might cause the increase of LDL, especially oxidized LDL, which would be taken in mesangium cells (1). Further LDL itself and proinflammatory cytokines released from oxidized macrophages might damage the tissue of the renal interstitium. Our case indicates that LDL absorption im-proves macrophage function by reducing and removing LDL in blood, and shows the effectiveness by reducing cytokine levels. ConclusionWe can usually see refractory nephrotic pa-tients who have their long clinical courses of repeating remission and exacerbation, and who have already various medications. In some cases who have the restriction of treatment itself because of various toxic medications, LDL apheresis might have a good candidate of treatment.

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