Telitacicept and Tacrolimus Synergy in Managing Refractory Primary Membranous Nephropathy: Case Insights

BACKGROUND Refractory primary membranous nephropathy (pMN), characterized by persistent proteinuria despite immunosuppressive therapy, is frequently associated with phospholipase A2 receptor (PLA2R) antibodies. Recent advancements have emphasized the effectiveness of biological agents, particularly the novel recombinant fusion protein telitacicept, in treating this condition. However, only a limited number of published studies have reported the use of telitacicept in pMN treatment. This report presents a case of a man with refractory pMN successfully treated with a combination of telitacicept and tacrolimus. CASE REPORT A 32-year-old man had persistent lower-extremity edema for 6 months, with high levels of proteinuria and PLA2R antibodies. Renal biopsy confirmed the diagnosis of stage III membranous nephropathy. Initial treatment with corticosteroids and cyclophosphamide showed limited efficacy. The addition of tacrolimus improved symptoms to some extent, but corticosteroids had to be discontinued due to ophthalmic complications. Tacrolimus monotherapy, however, failed to further reduce the levels of proteinuria. Subsequently, the addition of telitacicept significantly lowered both levels of proteinuria and PLA2R antibodies within 2 weeks. After 6 months of this revised treatment, PLA2R antibody results turned negative. CONCLUSIONS This case report suggests that the combination of telitacicept and tacrolimus is a promising therapeutic approach for management of refractory pMN, particularly when conventional treatments have proven ineffective. It also highlights the importance of monitoring treatment response by measuring PLA2R antibody levels. Further studies are needed to confirm the long-term efficacy of the combination of telitacicept and tacrolimus in treatment of refractory pMN.