膜性肾病合并脑梗死、抗磷脂抗体阳性1例并文献复习

A Case of Membranous Nephropathy Complicated by Cerebral Infarction and Antiphospholipid Antibody Positivity, with a Review of the Literature

摘要: 本文报告一例42岁男性抗PLA2R抗体阳性膜性肾病患者，在常规泼尼松联合环孢素治疗效果不佳且出现明显副作用后，改用利妥昔单抗治疗。患者首次RTX输注半月后突发脑梗死，实验室检查显示抗磷脂抗体阳性，后经抗凝治疗好转。随访中aPL及抗PLA2R抗体均转阴，蛋白尿明显缓解，肾功能稳定。结合临床表现及免疫学结果分析，该病例提出了一种可能的关联：RTX治疗早期可能通过B细胞清除与再生导致免疫重建过程中的短暂自身抗体谱紊乱，从而诱发aPL暂时性升高及血栓事件。RTX在MN治疗中虽总体安全有效，可有效实现B细胞介导的免疫调控和蛋白尿缓解，但需警惕早期短暂性免疫高凝状态，临床应加强治疗期间aPL及凝血功能监测，并根据患者情况个体化抗凝干预，以防范潜在血栓并发症。

Abstract: This report describes a 42-year-old male with PLA2R-antibody-positive membranous nephropathy. His initial treatment with prednisone combined with cyclosporine produced a poor therapeutic response and caused significant side effects, so his physicians switched him to rituximab (RTX). Half a month after his first RTX infusion, he suddenly developed a cerebral infarction. Laboratory tests at that time showed positive antiphospholipid antibodies (aPL), and his condition improved after anticoagulation therapy was initiated. During follow-up, both aPL and anti-PLA2R antibodies turned negative, his proteinuria markedly improved, and his renal function remained stable. Based on the clinical course and immunologic findings, this case suggests a possible association, in the early stage of RTX therapy, the depletion and subsequent regeneration of B cells may temporarily disturb the autoantibody profile, leading to a short-term rise in aPL and an increased risk of thrombosis. Although RTX is generally safe and effective for the treatment of membranous nephropathy—achieving B-cell-mediated immune modulation and reduction of proteinuria—clinicians should be aware of a possible transient hypercoagulable state early after treatment. Strengthened monitoring of aPL levels and coagulation parameters, together with individualized anticoagulation when appropriate, may help prevent thrombotic complications.