Impact of proteinuria in cyclosporine-treated cadaveric renal transplant recipients

De novo lupus nephritis in a renal transplanted child: a case report

De novo lupus nephritis (LN) is a rare complication in renal transplantation recipients. We present the clinical manifestations of de novo LN in a 12-year-old boy who received a cadaveric renal transplant. The cause of end-stage renal disease was prune belly syndrome with renal dysplasia. His immunosuppressive drugs included tacrolimus, mycophenolate sodium, and prednisolone. After 3 years of treatment, he developed nephrotic syndrome (NS) without other symptoms of systemic lupus erythematosus (SLE). The renal pathology of the transplanted kidney showed suspicious acute cellular rejection and LN World Health Organization class IV-G (A/C). Antinuclear antibody was positive, but anti-dsDNA and anti-Smith were negative. The serum complements were initially normal. Pulse methylprednisolone was given and the dosages of all immunosuppressive drugs increased; notwithstanding, his edema and hypoalbuminemia worsened. Repeated biopsy of the transplanted kidney was done. A full-house pattern was documented under immunofluorescent examination which confirmed LN WHO class IV-G (A/C) without evidence of rejection. He then developed macrophage-associated hemophagocytic syndrome and cytomegalovirus pneumonia. He ultimately developed pulmonary hemorrhage and died owing to severe pneumonia. De novo LN should be considered in renal transplant recipients with new onset of NS despite there not being any other clinical manifestations of SLE.

Clinical significance of proteinuria at posttransplant year 1 in kidney transplantation

PURPOSE

Proteinuria in the nontransplant population is a progressive renal disease. We analyzed the prevalence and clinical significance of proteinuria as well as factors related to its degree at posttransplant year 1 among kidney transplant recipients.

METHODS

We measured protein in a 24-hour urine among 644 recipients from January 1996 to December 2010.

RESULTS

Among 372 male and 272 female recipients, the mean amount of urinary protein was 424.4 ± 1010 mg/d (range, 13.88-8691) including 388 (60.2%) subjects with microproteinuria and the other 256 (39.8%) with overt proteinuria. Nephrotic range proteinuria was observed in 17 (2.6%) and nonnephritic range proteinuria, in 239 (37.1%) recipients. The latter cohort was categorized into low-grade proteinuria (n = 224; 34.8%) and high-grade proteinuria (n = 15; 2.3%). Proteinuria at posttransplant 1 year highly correlated with serum creatinine values at posttransplant years 1 and 2 as well as estimated glomerular filtration rate but not creatinine clearance at postoperative year 2. A greater incidence of graft loss was observed among recipients with more severe proteinuria. Males, recipients with anti-hepatitis C virus antibody, unrelated donors, anti-thymocyte immunoglobulin at the time of reperfusion, maintenance immunosuppression with cyclosporine or without mycophenolate mofetil were strongly associated with the amount of proteinuria.

CONCLUSION

This study demonstrated the prevalence of proteinuria in kidney transplant recipient to be high. The presence as well as level of proteinuria were predictive markers for inferior allograft function.

Post-transplant nephrotic syndrome: A comprehensive clinicopathologic study

BACKGROUND

Post-transplant (Tx) nephrotic syndrome (NS) is not well defined.

METHODS

Seventy-four renal transplant recipients with NS were studied.

RESULTS

Biopsies showed chronic allograft nephropathy (CAN) in 31 patients; recurrent glomerular disease (GN) in 15, de novo GN in 18, and undetermined GN in 9. NS developed 0.25 to 384 months post-Tx and was treated with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) in 18 patients; calcium channel blockers in 25; or both drugs in 31. NS remitted in 24% of cases 2 to 28 months after onset, and this persisted in all except 3 patients. The remission rate was lowest (9%) for CAN and highest (47%) for de novo GN. Compared with persistent NS, those with remission showed higher prevalence of de novo GN (53% vs. 17%), lower prevalence of CAN (18% vs. 50%), earlier onset of NS (39 vs. 59 months), lower serum SCr at onset (2.3 vs. 2.9 mg/dL), and higher incidence of treatment with ACE or ARB. The 5-year graft loss rates for CAN, recurrent and de novo GN were 57%, 36%, and 23%, respectively. Compared with the functioning grafts, the failed grafts showed higher prevalence of CAN (60% vs. 16%), lower prevalence of de novo GN (12% vs. 46%), earlier onset of NS (47 vs 65 months post-Tx), higher serum SCr at onset (3.3 vs. 2.0 mg/dL), lower prevalence of remission of NS (5% vs. 48%), and higher proteinuria at follow-up (5.1 vs. 2.5 g/day). Graft survival improved with NS remission (88% vs. 18%).

CONCLUSION

Post-Tx NS displays distinctive clinicopathologic features with pathogenetic and therapeutic implications.