Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a distinct form of glomerulonephritis that often recurs after kidney transplantation causing severe graft injury and often failure.
We describe post transplant outcomes and response to therapy in 20 recipients with PGNMID. Evidence of PGNMID recurrence or lack thereof was determined by protocol and clinical biopsies.
Histologic recurrence (deposition of monoclonal immunoglobulin) occurred in 18 of 20 recipients (90%), a median of 7 (1 to 65) months post transplant. At diagnosis, recurrence was generally associated with mild or no clinical manifestations and often with mild glomerular morphologic changes by light microcopy. Four of the 18 patients with recurrence did not progress and were not treated. Another 4 patients with recurrences were treated with cyclophosphamide with or without plasmapheresis, and 2 of these grafts were lost from glomerulonephritis. Nine patients with recurrences were treated with anti-CD20 antibodies (rituximab) alone, resulting in improvements in estimated glomerular filtration rate (31.5 ± 16 versus 38.8 ± 13.3 mL/min/1.73 m2, P = 0.011) and proteinuria (1280 [117 to 3752] versus 168 [83 to 1613] mg/24 h, P = 0.012) although complete clinical remission was rare. One graft in this later group was lost from recurrence 141 months post transplant. Posttreatment biopsies demonstrated stable or improved glomerular histology in most cases. However, PGNMID did not resolve in any case. Four patients received rituximab 4 months pretransplant to prevent recurrence. However, 3 had mild recurrences.
Rituximab treatment of early PGNMID recurrence is effective, resulting in reasonable, long-term graft survival. Whether pretransplant rituximab modifies the course of recurrence requires additional studies.
1 Division of Nephrology and Hypertension, Department of Internal Medicine, William von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.
2 Division of Nephrology and Hypertension, Department of Nephrology, Hospital del Mar, Barcelona, Spain.
3 Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
Received 6 September 2018. Revision received 4 December 2018.
Accepted 6 December 2018.
This work was supported by internal Mayo Clinic grants.
A.B. participated in data collection, analysis, and manuscript preparation. S.M.S. and S.H.N. participated in review of all biopsies, data analysis, and manuscript review. N.L. and M.El.T. participated in research design, data analysis, and manuscript review. F.G.C. participated in research design, data collection and analysis, and manuscript preparation.
The authors declare no conflicts of interest.
Correspondence: Fernando G. Cosio, MD, Division of Nephrology and Hypertension, Department of Internal Medicine, William von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, 200 First St SW, Rochester, MN 55905. (firstname.lastname@example.org).