De novo membranoproliferative glomerulonephritis III in a renal transplant patient: case report and review of the literature

Abstract

Idiopathic membranoproliferative glomerulonephritis (MPGN) is a rare cause of renal failure with a cumulative incidence of 0.3% of all ESRD and 4% of all primary glomerulonephritis for types I and II. Membranoproliferative glomerulonephritis type III is more uncommon and idiopathic de novo MPGN III in a renal transplant patient has not been reported. We present the case of a 57-year old white female patient with a diagnosis of lithium toxicity as cause of end stage renal disease (ESRD) who developed MPGN III in her allograft 6 years after a renal transplant. Despite treatment, she progressed to ESRD within four and a half years from the time of diagnosis.

Figure 1. Native Kidney Biopsy

(A) The native kidney biopsy shows a relatively unremarkable glomerulus with only mild mesangial hypercellularity (Hematoxylin and Eosin stain; 40x). (B) There is no evidence of capillary loop duplication or “spike” formation on the Jones’ methanamine silver (B, 40x magnification) stain. (C, D) Transmission electron microscopy of the native kidney biopsy shows segmental effacement of the podocyte foot processes (arrowhead). The glomerular basement membrane is of normal thickness with accentuated wrinkling. There is a single subendothelial electron dense deposit (arrow). Notably, no subepithelial electron dense deposits are seen. (7700x magnification)

Figure 2. Allograft Kidney Biopsy

(A) Toluidine blue stained plastic section (60x magnification) of the allograft biopsy shows a lobular appearing glomerulus with duplication of the capillary loops (arrows). (B, C, & D) Transmission electron microscopy of the allograft kidney biopsy demonstrates diffuse thickening of the glomerular basement membrane by subepithelial/intramembranous (arrowheads), and subendothelial (arrows) electron dense deposits. The deposits have no discernable substructure. Focally, the glomerular basement membrane is duplicated. Significant podocyte foot process effacement is seen. These findings support the diagnosis of membranoproliferative glomerulonephritis type III. (B, D 10,000x and C 6,250x magnification)