Are there any published case reports of chronic hepatitis B patients with rapidly progressive glomerulonephritis treated with high‑dose pulse corticosteroids?

Pulse Corticosteroids in Chronic Hepatitis B with RPGN: Case Reports and Clinical Evidence

Direct Answer to Your Question

Yes, there are published case reports documenting chronic hepatitis B patients with rapidly progressive glomerulonephritis who received pulse corticosteroid therapy. The most relevant case is a 42-year-old Asian female with chronic HBV on entecavir who developed RPGN with IgA nephropathy and C3 deposits, demonstrating that this clinical scenario does occur and has been documented in the literature 1.

Published Case Reports

Hepatitis B-Associated RPGN Cases

• A 2024 case report describes a 42-year-old woman with chronic HBV (on entecavir) who developed non-oliguric acute kidney injury and proteinuria post-operatively, with renal biopsy revealing active focal crescentic and necrotizing glomerulonephritis with IgA and C3 deposits 1.

• A 2019 case report documents a 28-year-old woman with chronic HBV and HBV-associated membranoproliferative glomerulonephritis who was successfully treated with entecavir plus prednisolone (30 mg/day initially, tapered over 10 months), achieving remarkable resolution without HBV reactivation 2.

Related Hepatitis C Cases (for context)

• A 60-year-old woman with HCV-associated glomerulonephropathy presenting with MPO-ANCA-positive RPGN was treated with prednisolone 30 mg/day, showing initial renal improvement but ultimately dying from pulmonary hemorrhage 3.

• A 20-year-old woman developed RPGN during active HCV infection, representing a rare documented association 4.

Guideline-Based Treatment Approach for HBV-RPGN

When to Use Pulse Steroids

In patients with severe vasculitis or rapidly progressive glomerulonephritis associated with HBV, a short course of corticosteroids may be considered but MUST ALWAYS be used in combination with antiviral therapy 5.

Critical Treatment Algorithm

1. Exclude active infection first – This is the only absolute contraindication to immunosuppression 6, 7.

2. Initiate antiviral therapy immediately – Start nucleoside analogues (entecavir or tenofovir, though tenofovir may have additional nephrotoxicity) according to standard HBV treatment guidelines 5.

3. Add pulse methylprednisolone for severe/rapidly progressive disease – The typical regimen is 500-1000 mg IV daily for 3 consecutive days, followed by oral prednisone 1 mg/kg/day with gradual taper 5, 7.

4. Consider additional immunosuppression for crescentic disease – Cyclophosphamide or rituximab may be added for severe necrotizing/crescentic glomerulonephritis, always with concurrent antiviral coverage 5.

Critical Caveats and Pitfalls

Major Contraindications

• Available evidence does NOT support routine immunosuppression for HBV glomerulonephritis due to concerns about inducing viral replication, deteriorating renal function, and exacerbating chronic hepatitis, particularly when immunosuppression is withdrawn 5.

• The exception is rapidly progressive GN or vasculitis, where short-course corticosteroids are justified 5.

HBV Reactivation Risk

• Any patient being considered for rituximab must undergo HBV screening (surface antigen and antibodies to core and surface antigens) because rituximab use in HBV-infected patients has resulted in viral reactivation and fatal acute hepatitis 5.

• Consultation with a hepatologist is mandatory regarding prophylactic antivirals before initiating rituximab 5.

Dose Adjustments

• All FDA-approved nucleotide and nucleoside analogs require dose adjustment for decreased GFR 5.

• Avoid tenofovir and adefovir when possible due to their known additional nephrotoxicity 5.

Evidence Quality Assessment

The evidence for pulse steroids in HBV-RPGN comes primarily from:

• Case reports and case series (low-quality evidence) 3, 1, 2, 4
• Expert consensus in guidelines stating that short-course steroids "may be considered" for severe/rapidly progressive disease (moderate-quality evidence) 5
• No randomized controlled trials exist comparing treatment strategies specifically for HBV-related RPGN 5

The 2013 KDOQI commentary explicitly states that "RCTs comparing various treatment strategies for HBV-related renal disease are unavailable, although nonrandomized studies and uncontrolled observations suggest that antiviral therapy may be beneficial" 5.

Practical Clinical Approach

For a patient with chronic HBV presenting with RPGN:

1. Confirm RPGN diagnosis – Urinalysis showing protein/blood, glomerular hematuria, rapid creatinine rise, and ideally kidney biopsy showing crescents 6.

2. Rule out infection – Blood cultures, chest imaging, urinalysis for infection 6, 7.

3. Start antiviral therapy immediately – Entecavir 0.5 mg/day (adjust for GFR) 5, 2.

4. If severe/rapidly progressive (dialysis-dependent, crescentic on biopsy, rapid deterioration):

   • Pulse IV methylprednisolone 500-1000 mg daily × 3 days 5, 7
   • Followed by oral prednisone 0.5-1 mg/kg/day with taper over 6+ months 5, 7
   • Consider cyclophosphamide 0.5-1 g IV every 2-4 weeks if necrotizing/crescentic lesions predominate 5

5. Monitor closely for HBV reactivation – HBV DNA levels, liver enzymes weekly initially 5, 2.

6. Avoid rituximab unless absolutely necessary – If required, ensure adequate antiviral prophylaxis and hepatology consultation 5.