A 48-year-old man presented with proteinuria for 9 years.
He had hypertension of 2 years of evolution in treatment with asbestos, atenolol and irbesartan for years.
In the general study, the following stood out: proteinuria 1200 mg/day, urinary incontinence 448 mg/μl in sediment, creatinine 1.05 mg/dl and negative immunology.
In renal biopsy: 5 glomeruli without striking cellularity, without exudation, 2-4 glomeruli with complete distribution of IgM and segmental lymphocytic infiltration with discrete focal lymphofluorocytic infiltration.
The patient was oriented as focal segmental glomerulonephritis adding 2.5-5 mg/day of cyclosporine to <400 mg/day.
Three years ago, the patient suffered an increase in proteinuria 1.6 g/day, albuminuria 895 mg/day and bilirubin levels 250 mg/μl, with normoalbuminemia and edema.
She was treated with prednisone and cyclophosphamide, with a decrease in proteinuria after 7 months of treatment up to 1.1 g/day, but with proximal muscle weakness that was interpreted as steroid myopathy.
Prednisone was discontinued and switched to mycophenolate mofetil 1 g/day. Prednisone was withdrawn due to its potential influence on edema, adding 12.5 mg hydrochlorothiazide due to poor blood pressure control.
At 2 months, mycophenolate was discontinued because the patient experienced significant tiredness that she attributed to this drug.
Cyclosporine A was then initiated at a dose of 150 mg/day (1.9 mg/kg/day) with good initial tolerance (levels 67.8 ng/ml).
At 2 months the patient consulted for pain in the left breast accompanied by a retroareolar nodule sensitive to touch, size of a chestnut.
Cyclosporine A was suspended, mammography and ultrasound showed glandular increment without signs of malignancy, so it was interpreted as drug-related glandular hyperplasia.
Eight months later tacrolimus was administered (6 mg/day initial with a reduction after 4-5 mg/day with levels <8 ng/ml).
Two months later, the patient presented with new left breast pain, which was suspended due to proteinuria <250 mg/day.
In the last review 5 months later, proteinuria had risen to 650 mg/day and had dropped glandular growth, leaving it under treatment with doxazosine, atenolol, irbessartan and ivabradine.
