The management of a patient with rheumatoid arthritis (RA) and chronic kidney disease (CKD) represents a recognized therapeutic dilemma. CKD is a limiting factor for the use of synthetic DMARD (disease modifying antirheumatic drugs) such as methotrexate, because of an increased risk of toxicity making them unsafe. Therefore, the availability of therapeutic alternatives would improve our treatment options in CKD patients with RA. Clinical studies addressing the efficacy and safety of biological DMARD in patients with CKD on dialysis are rare, and usually these patients are excluded from clinical trials. We only found a few clinical cases in the literature regarding the use of anti-TNF in patients with CKD undergoing dialysis.1–4 Therefore, we decided to report a clinical case of a patient with RA and CKD on hemodialysis that we successfully treated with an anti-TNF.

We present a case of a 71-year old women with RA with more than 15 years of disease duration. She was previously treated with methotrexate, which was interrupted by end-stage CKD, and hemodialysis was started. Disease activity was controlled for 2 years with low-dose prednisolone. However, due to clinical RA worsening (DAS-28 (Disease Activity Score-28) of 5.25) and development of an osteoporotic fracture, it was decided to modify the therapy to better control RA and tapper corticosteroid dose.

Anti-TNF agents are hydrolyzed by lysosomes and their excretion does not appear to be influenced by renal function.1,5 Thus, these agents are a possible therapeutic alternative in patients with CKD. There are some case series with a small number of patients that show efficacy and safety of Infliximab,2 Adalimumab3 and Etanercept4,5 in patients with CKD on dialysis.

Based on these data, we decided to start Etanercept on monotherapy. Etanercept is usually used in RA at a dose of 50mg once a week. In our patient, a 25mg dose twice per week was chosen (injection after hemodialysis session). Although Don and collaborators demonstrated that hemodialysis did not affect Etanercept excretion,5 we decided to choose 25mg twice a week instead of 50mg once a week. At one year of follow-up, the patient has a good response (DAS-28 2.81) and there were no adverse events registered.

We present the first case of our center with the use of an anti-TNF in a patient undergoing hemodialysis, with good response and no adverse events. Anti-TNF drugs appear to be safe and effective in CKD under dialysis, however, clinical experience is still insufficient.