L MCMICHAEL1, S MURTHY1, G IRISH1, S CHANG2, P COATES1, S MCDONALD1
1Central and Northern Adelaide Renal and Transplantation Service, Adelaide, Australia, 2SA Pathology, Adelaide, Australia
Background: Recurrent mesangiocapillary glomerulonephritis (MCGN) post transplantation is a common cause of graft loss with rates of recurrence from 19 to 48% with up to 88% of grafts failing following recurrence. Various strategies have been employed to manage recurrent disease post-transplantation, however there is limited data on pre-emptive management of patients at transplantation.
Case Report: We report a case of a 63-year-old woman with immune-complex-mediated MCGN receiving a second renal transplant following recurrence in her 2/6 HLA mismatched primary transplant. Primary transplant recurrence was identified on biopsy day 76 following development of proteinuria and increasing creatinine. This was managed with cyclophosphamide and plasma exchange with return to long term haemodialysis at day 86. After 10 years on haemodialysis the patient received a second well matched deceased donor transplant with 0/6 HLA mismatches. Induction immunosuppression included anti-thymocyte globulin at day 0,1,2, plasma exchange at day 3 and rituximab 1g at day 5 and 18. Routine protocol biopsy at day 79 demonstrated minimal tubulitis and no recurrent primary disease. A subsequent biopsy was performed at day 197 due to elevated creatinine following clostridium difficile infection which demonstrated no recurrent disease. She has been maintained on prednisolone, mycophenolate mofetil and tacrolimus with stable graft function at 7 months.
Conclusions: The optimal therapy for managing patients with idiopathic MCGN at the time of transplantation is unknown. We demonstrate a novel protocol utilising planned rituximab and plasma exchange for pre-emptive management of patients with idiopathic MCGN with no sign of recurrence at 7 months post transplantation.
Nephrology Registrar at Central Northern Adelaide Renal and Transplantation Service.