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Abstract: SA-PO876

Successful Use of Euro Lupus Regimen in PLA2R-Negative Recurrent Membranous Nephropathy After Kidney Transplant

Session Information

Category: Transplantation

  • 2002 Transplantation: Clinical

Authors

  • Amin, Sahar, The University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, United States
  • Balaraman, Vasanthi, The University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, United States
  • Bhalla, Anshul, The University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, United States
  • Talwar, Manish, The University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, United States
  • Rustom, David S., The University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, United States
  • Wall, Barry M., The University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, United States
Introduction

Membranous nephropathy (MN) may recur after transplant. Recurrent post-transplant MN can occur in approximately 40% of patients, usually within the first year. The antibody most often implicated is M-type phospholipase A2 receptor (PLA2R) found in >70% of primary MN cases.

Case Description

30 year-old male with ESRD secondary to PLA2R negative MN underwent a deceased-donor kidney transplant using induction with ATG. He was discharged with a creatinine of 1.9 mg/dL with UPCR 0.4 and maintained on tacrolimus (goal level 8-10 ng/ml), MMF 750mg twice a day and prednisone 5 mg/day. At two months post-transplant, he developed proteinuria (UPCR of 2.2) and started losartan at 100 mg/day. A graft biopsy revealed recurrent post-transplant MN. Immunohistochemical staining was negative for PLA2R, THSD7A, NELL1, EXT1, EXT2. Despite optimal RAAS blockade proteinuria worsened, Rituximab was given 4 times as 500-mg doses two weeks apart after which proteinuria came down to UPCR of 0.4. He then developed nephrotic range proteinuria UPCR of 4.2 again at 9 months post transplant. He was given another course of Rituximab 500mg weekly x 4 and ACTH gel 40 units SC twice a week after which proteinuria came down to UPCR of 1.8. 15 months post transplant, he presented with AKI (creatinine of 9 mg/dl), UPCR of 9, requiring hemodialysis. Repeat allograft biopsy showed persistent active MN along with, Banff Bordline TCMR and AMR with positive DSA against DQB1 MFI 4700. He was given pulse dose methylprednisone 500 mg daily x 3 days for ongoing active MN. Since patient had MN refractory to Rituximab, treatment with Cyclophosphamide (CP) was initiated, 500mg every two weeks, total of six doses along with prednisone 70 mg once daily which was slowly tapered. We chose the Euro Lupus regimen to minimize cumulative toxicity of oral CP regimen. For treatment of AMR, he received five sessions of plasmapheresis . His allograft function slowly improved and his creatinine came down to baseline of 1.9 mg/dl and proteinuria stabilized at around 1.2 g/g.

Discussion

This is the first report on use of IV low dose CP for treatment of post transplant recurrent MN. Our case describes the management strategy of a very difficult recurrent post-transplant PLA2R negative MN that was highly resistant to standard first line treatment.