A case of recurrent proliferative glomerulonephritis with monoclonal IgG deposits after kidney transplant treated with plasmapheresis

Abstract

Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) is a rare and recently identified disease with a poor prognosis irrespective of the treatment. Recently, the possibility of recurrent or de novo PGNMID after kidney transplantation has been reported, which is associated with a better prognosis compared to PGNMID on native kidneys. Nevertheless, at present, due to the very few cases of recurrent PGNMID diagnosed, there is no proven effective treatment. Here, we report a case of recurrent PGNMID successfully treated with plasmapheresis, steroids and mycophenolate mofetil. Our report suggests that plasmapheresis might be a valid therapeutic option to treat recurrent PGNMID.

Keywords: Glomerulonephritis; Monoclonal IgG; Plasmapheresis; Recurrence.

Fig. 1

A, B Histology of the native kidney. The glomeruli show segmental cellular crescent (A, B) and diffuse endocapillary hypercellularity (B). C, D Histology of the graft (first biopsy). The glomeruli show the same pattern found on the native kidneys with extracapillary proliferation (C) and endocapillary proliferation (D; periodic acid-Schiff; original magnification ×400). E IF performed on the graft (first biopsy) shows a strong granular capillary staining of the glomerulus in the mesangium and in the subendothelial sites (IgG, original magnification ×400). F A similar pattern was found on the native kidney (single light-chain isotype κ, original magnification ×400). G Electron microscopy from the first transplant biopsy shows large granular subendothelial electron-dense deposits (original magnification ×5,200). H Electron microscopy of the native kidney shows the same pattern with subendothelial and mesangial electron-dense deposits (original magnification ×3,000).

Fig. 2

A, B Histology of the graft (second biopsy) after plasmapheresis treatment show less disease activity. The glomeruli show only a segmental mesangial hypercellularity (periodic acid-Schiff; original magnification ×400). C, D IF performed on the graft (second biopsy) displays only a slightly segmental mesangial staining of the glomerulus (IgG, original magnification ×400).E, F Representative images of the histology of the graft after transplant nephrectomy showing one normal glomerulus and one with mesangial hypercellularity (E), and one glomerulus with segmental cellular crescent (F; periodic acid-Schiff; original magnification ×400).