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Kidney Week

Abstract: SA-PO347

Clinical Characteristics and Renal Outcomes in Patients Developing Membranous Nephropathy After Allogeneic Stem Cell Transplantation

Session Information

Category: Glomerular Diseases

  • 1202 Glomerular Diseases: Immunology and Inflammation

Authors

  • Shingarev, Roman A., Memorial Sloan Kettering Cancer Center, New York, New York, United States
  • Jakubowski, Ann A., Memorial Sloan Kettering Cancer Center, New York, New York, United States
  • Seshan, Surya V., Weill Cornell Medical Center, New York, New York, United States
  • Jaffer Sathick, Insara, Memorial Sloan Kettering Cancer Center, New York, New York, United States
  • Jaimes, Edgar A., Memorial Sloan Kettering Cancer Center, New York, New York, United States
  • Glezerman, Ilya, Memorial Sloan Kettering Cancer Center, New York, New York, United States
Introduction

The overall probability of developing nephrotic syndrome (NS) in allogeneic stem cell transplant (allo-SCT) patients with graft-versus-host disease (GVHD) is estimated to be 8%. Membranous nephropathy (MN) accounts for the majority of these cases and has been ascribed to renal-specific manifestation of GVHD based on MN association with GVHD in other organs, immunosuppression (IS) reduction at the time of MN diagnosis and negative tissue PLA2R staining. Treatment regimens range from corticosteroids (CS) to rituximab with variable clinical response.

Case Description

Chart review identified 8 cases of clinically diagnosed NS at our institution that developed after allo-SCT from 2010 through 2017 and was evaluated with kidney biopsy. No transplants had antigen mismatch. All had a history of, but no concurrent GVHD in the settings of IS reduction. Minimal change disease was responsible for 3 and MN for 5 cases. Stain for PLA2R was present in the glomerular capillary loops in 4 of 5 MN cases. Plasma PLA2R titers were negative when checked. Partial or complete remission of proteinuria (PTN) was achieved in 4 MN cases with the utilization of single agent Tacrolimus or its combination with CS, without complications arising from the treatment (Table).

Discussion

We report a series of MN cases diagnosed after allo-SCT and characterized by PLA2R-positive tissue staining. Although the presence of PLA2R in the glomerular tissue is thought to be specific for idiopathic MN, our findings raise the possibility of PLA2R being an epi-phenomenon occurring in both idiopathic and GVHD-related MN. Tacrolimus alone appears to be effective in inducing at least partial remission of PTN. Additional CS may confer a faster and more durable response; however, this benefit must be weighed against the side effects associated with their long-term use.

PatientAgeHematological DiagnosisPost-transplant time (d)GVHD statusPLA2R tissuePLA2R
Plasma
Initial TreatmentTreatment duration (d)Treatment response
(UPC)
Subsequent treatment
155AML839prior+-Tacrolimus + CS160partial
(1.0)
none
266MDS864prior+IndeterminateTacrolimus + CS294complete
(0.1)
none
335TCL937prior+not checkedTacrolimus394complete
(0.1)
Tacrolimus
473AML1248prior+-Tacrolimus90none
(17)
Tacrolimus + CS
556AML1065prior-not checkedTacrolimus747partial
(1.5)
Mycophenolate Mofetil

AML, acute myeloid leukemia; CS, corticosteroids; GVHD, graft-versus-host disease; MDS, myelodysplastic syndrome; TCL, T-Cell lymphoma