it is classified into type 1 ( monoclonal due to paraprotein disorders ) , type 2 ( mixed polyclonal and monoclonal secondary to hepatitis c ) , and type 3 ( polyclonal due to lymphoproliferative disorders ) . the most common type described in the literature is secondary to hepatitis c , with a prevalence described as high as 50% . renal disease in mixed cryoglobulinaemia is present in approximately 20% of patients at the time of diagnosis . clinical presentation encompasses a wide variety of features from generalised bruising , hepatosplenomegaly , and acute renal failure to peripheral neuropathy and hypocomplementaemia [ 3 , 4 ] . endocapillary proliferation , intraluminal thrombi , and thickening of the glomerular basement membrane are the most specific histological findings for type 2 cryoglobulinaemia . the current mainstay of management includes plasmapheresis with high - dose prednisolone and cyclophosphamide and treatment of the underlying cause . rituximab is a monoclonal anti - cd20 antibody used in the treatment of a variety of autoimmune diseases . we describe a case of type 2 mixed cryoglobulinaemia associated with non - hodgkin 's lymphoma successfully treated with rituximab . a 61-year - old female presented with severe community - acquired pneumonia complicated by acute renal failure . the renal failure was attributed to acute tubular necrosis secondary to sepsis and hypotension . at that time the patient was discharged home after 45 days of hospital stay with normal renal function . she represented with acute pulmonary oedema and skin rash , requiring readmission to the intensive care unit within 48 h of discharge . physical examination was consistent with pulmonary hypertension , splenomegaly , hepatomegaly , and bilateral pleural effusion . her positive investigations were : dysmorphic red cells in urine , proteinuria ( 24-hour urine protein 1 g ) , hypoalbuminaemia ( serum albumin 24 g / l ) , low complement levels , and positive serology for mixed cryoglobulinaemia . rheumatoid factor was weakly positive and hcv rna was negative , as were all other autoimmune screens . renal biopsy revealed diffuse mesangiocapillary glomerulonephritis accompanied by hyaline capillary thrombi with focal mild endarteritis affecting the intimal zone of one small artery consistent with cryoglobulinaemic vasculitis ( fig . 1 , fig . the patient was treated with 5 sessions of plasma exchange and 2 sessions of haemodialysis over 1 week , followed by prednisolone and cyclophosphamide . there was a good initial response with a decrease in cryoglobulin levels within 3 weeks and symptomatic improvement . the patient was discharged on prednisolone 50 mg daily , and her renal function was normal on discharge . however , she became symptomatic again on prednisolone after 2 weeks , with reappearance of rash . the patient 's urea level was disproportionately high ( with steroids and diuretics on board ) compared to her creatinine level . she required 5 sessions of plasmapheresis and was recommenced on reduced cyclophosphamide with a dose of 50 mg/100 alternate days . cyclophosphamide was ceased due to recurrent thrombocytopenia , sepsis , and herpes zoster of the chest wall on the left side . she was commenced on intermittent haemodialysis ( for better control of uraemia and fluid retention ) and plasmapheresis on alternate days for 1 month . mg / l ) , but negative bence jones protein in urine , normal skeletal survey , and no light chains in the serum . her bone marrow biopsy showed a low - grade lymphoma with predominant cd20 expression on b cells . as the patient was not showing any clinical improvement and was requiring regular dialysis / ultrafiltration , second - line treatment was discussed . she was given 600 mg rituximab / week for 3 weeks in addition to prednisolone and responded within 1 week , with dramatic improvements in symptoms , absence of cryoglobulins , and normal complement levels . in view of her multiple prior infections ( pneumonia , herpes zoster , and urosepsis ) , it was decided to administer only 3 doses of rituximab . her renal function gradually improved , and she became dialysis independent after 7 months , with complete renal recovery . cryoglobulin titres have remained negative and serum complements normal over the current follow - up of 24 months . non - hodgkin 's lymphoma - associated cryoglobulinaemia presenting with acute renal failure is uncommon . to our knowledge , this is the first case report of a patient with mixed cryoglobulinaemia associated with non - hodgkin 's lymphoma who presented with nephritis and acute renal failure [ 7 , 8 ] . our patient was responsive to prednisolone , plasmapheresis , and cyclophosphamide but had a recurrence which was resistant to cytotoxics , steroids , and plasma exchange . rituximab has been shown to be useful in essential and secondary cryoglobulinaemia [ 7 , 9 ] . it is a human - mouse chimeric monoclonal antibody that reacts with cd20 antigen , a transmembrane protein present in different maturation steps of b lymphocytes ( from early pre - b to mature lymphocyte ) , thus directly and selectively targeting b cells and suppressing the production of rheumatoid factor [ 7 , 10 ] . rituximab has proved effective and very well tolerated in b - cell non - hodgkin 's lymphomas [ 7 , 11 , 12 ] , but there are conflicting case reports as well [ 13 , 14 ] . rituximab has the advantage of allowing avoidance of serious immunosuppression and side effects [ 7 , 11 ] and it lacks direct oncogenetic properties that could favour the progression of indolent lymphomas into an aggressive lymphoma . although a complete and long - term remission of lymphoma is obtained in a minority of cases after rituximab monotherapy , this case is unique for the fact that our patient has not shown signs of clinical or serological recurrence for 24 months after treatment with rituximab . she has not required maintenance therapy , although concerns about rituximab not being curative and need for ongoing rituximab maintenance therapy have been raised . the patient showed complete recovery with regard to renal function , although acute renal failure on presentation in mixed cryoglobulinaemia implies poor prognosis . the usual regimen consists of 375 mg / m with 1 dose per week for 4 weeks . the fourth dose was not given because of pancytopenia secondary to cytotoxics and sepsis predating the use of rituximab . our case report highlights the ongoing necessity for further exploration of new therapeutic agents in the treatment of resistant cryoglobulinaemia associated with lymphoma . no study has yet examined the efficacy of rituximab in mixed cryoglobulinaemia in a prospective controlled manner . the current literature is restricted to case reports and case series , and further prospective study is needed to fully determine the role of rituximab . resistant cryoglobulinaemia is a life - threatening condition , and the optimal management is unknown at this moment . rituximab has emerged as a well - tolerated and effective treatment with no long - term oncogenetic potential , which was confirmed by this case report .