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Kidney Week

Abstract: PO2552

De Novo Membranous Nephropathy and Donor-Specific Alloantibodies: A Path to the Pathophysiology?

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Tierney, Megan Ann, University of Mississippi Medical Center, Jackson, Mississippi, United States
  • Vaitla, Pradeep, University of Mississippi Medical Center, Jackson, Mississippi, United States
  • Cheungpasitporn, Wisit, University of Mississippi Medical Center, Jackson, Mississippi, United States
  • Cabeza Rivera, Franco H., University of Mississippi Medical Center, Jackson, Mississippi, United States
Introduction

While pathophysiology of post-transplant membranous nephropathy due to recurrence of primary disease is established, less is known about the development of primary de novo membranous nephropathy (dnMN). We report a case of dnMN associated with antibody-mediated rejection in a transplant recipient with end-stage kidney disease secondary to focal segmental glomerulosclerosis (FSGS).

Case Description

A 20-year-old African American female with FSGS status-post deceased donor kidney transplant eight years ago presented with acute lower extremity edema and acute kidney injury concerning for acute rejection. She has no history of prior rejection or medication non-adherence. Ultrasound showed mild hydronephrosis. Biopsy showed Banff Type IB acute-cell mediated rejection (t2, i2) and Stage 1 membranous glomerulopathy. Serum phospholipase A2 receptor (anti-PLA2R) antibodies were negative. Donor specific antibodies (DSA) testing revealed the presence of DQ5, DQ7, and DRB1*01:03.

Diagnosis of coexistence of Banff Type IB acute-cell mediated rejection, positive de novo DSA, and dnMN was made. She was treated with five doses of antithymocyte globulin (1.5 mg/kg/dose) and plasma exchange (PLEX) followed by IV immune globulin (IVIg). Repeat DSA after fifth session of PLEX showed clearance of DRB*01:03 and reduced DQ antibody levels; after seventh session of PLEX, however, DQ antibodies had plateaued. Biopsy performed after PLEX and antithymocyte globulin showed chronic active T cell-mediated rejection Grade IB (ti3, t3, and I-IFTA2) and persistent Stage 1 membranous glomerulopathy; in the setting of persistent DQ antibodies, this suggested failure of transplanted organ within the next 6-12 months. The patient was prepared for this eventuality, received a final session of PLEX and IVIg and discharged in otherwise stable condition.

Discussion

Only one case of dnMN associated with HLA-DQ7 DSA has been previously reported (El Kossi Clin Transplant 2008). This case not only reports the unique occurrence of two glomerulonephropathies in one patient, but also provides support that post-transplant dnMN can be seen in the context of humoral alloreactivity, and DSA might play some roles for the pathogenesis in some patients with dnMN after kidney transplantation (Honda Clin Transplant 2011).