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Liu MY, Yu XJ, Wang SX, Li Y, Xing GL, Chen M, Zhou FD, Zhao MH. Characteristics of Complement Protein Deposition in Proliferative Glomerulonephritis with Monoclonal Immunoglobulin Deposition. Clin J Am Soc Nephrol 2023; 18:1573-1582. [PMID: 37713183 PMCID: PMC10723927 DOI: 10.2215/cjn.0000000000000295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Hypocomplementemia and complement co-deposition with monoclonal immunoglobulins in glomeruli are not rare in proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID). Deposition of monoclonal immunoglobulins in glomeruli has been suggested to activate complement and cause kidney injury. However, the profiles of complement activation in PGNMID and their clinical and pathologic significance need to be clarified. METHODS Forty-six patients with PGNMID were enrolled. Proteomic analysis of glomeruli using laser microdissection and mass spectrometry was performed for ten patients with PGNMID to determine the composition of glomerular deposits. Kidney deposition of complement components was detected by immunohistochemistry and immunofluorescence. Urinary and plasma levels of complement components were measured by an enzyme-linked immunosorbent assay. Group differences were assessed using t tests or Mann-Whitney U tests depending on the distribution. Correlation analysis was performed using Spearman rank correlation or Pearson correlation. RESULTS Laser microdissection and mass spectrometry-based proteomic analysis showed that complement components were the most enriched proteins deposited in the glomeruli of patients with PGNMID. Glomerular deposition of C3c, C4d, and C5b-9 was detected in most patients. Levels of urinary and plasma C3a, C5a, soluble C5b-9, C4d, Bb, and C1q as well as urinary mannose-binding lectin were significantly higher in patients with PGNMID compared with healthy controls. The intensity of C3c and C4d deposition in glomeruli correlated with serum creatinine and the percentage of crescents, respectively. Furthermore, levels of urinary complement components correlated positively with serum creatinine, urinary protein excretion, percentage of crescents, and global glomerulosclerosis in kidney biopsies, whereas plasma levels of most complement components did not show a significant correlation with clinicopathologic parameters. In multivariable analysis, a higher level of urinary C4d was identified as an independent risk factor of kidney failure. CONCLUSIONS The complement system was found to be overactivated in PGNMID, and levels of urinary complements correlated with disease severity. A higher level of urinary C4d was identified as an independent risk factor of kidney failure.
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Affiliation(s)
- Meng-yao Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Xiao-juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Su-xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Yuan Li
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guo-lan Xing
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ming Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Fu-de Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Ming-hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
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Uchida T, Oda T, Hoshino T, Sakai T, Kojima A, Inoue D, Kojima T, Yamada M. Proliferative glomerulonephritis with monoclonal immunoglobulin G3 lambda deposits accompanied by glomerular positive staining for nephritis-associated plasmin receptor and related plasmin activity: A report of two cases. Front Med (Lausanne) 2023; 9:1059575. [PMID: 36714098 PMCID: PMC9877447 DOI: 10.3389/fmed.2022.1059575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/29/2022] [Indexed: 01/13/2023] Open
Abstract
Proliferative glomerulonephritis with monoclonal immunoglobulin (Ig) G deposits (PGNMID) is a relatively uncommon entity of monoclonal gammopathy of renal significance, and its detailed pathogenesis is not well understood. We, herein, report two cases of patients with PGNMID; their renal biopsy showed glomerular histological features of membranoproliferative glomerulonephritis pattern with endocapillary proliferation accompanied by non-organized granular electron-dense deposits that consisted of monoclonal IgG3-lambda. Neither symptomatic episodes of preceding infection nor infection foci were found in both patients; however, glomerular positive staining for nephritis-associated plasmin receptor (NAPlr) and related plasmin activity were observed. Although NAPlr was originally considered as a candidate nephritogenic protein for post-streptococcal acute glomerulonephritis, its positive staining and related plasmin activity have been observed in glomeruli of various cases with bacterial infection-related glomerulonephritis and is considered to be a general histological biomarker of infection-related glomerulonephritis. The present cases suggest that evaluation of immunoreactivity for NAPlr and related plasmin activity in glomeruli provides an important clue regarding the infection-related pathogenesis of PGNMID.
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Madireddy N, Patil R, Priyadarshini S, Varma MC, Garre S, Gowrishankar S. Proliferative Glomerulonephritis with Monoclonal Immunoglobulins in a Child with Recurrence in the Allograft. Indian J Nephrol 2023; 33:65-69. [PMID: 37197047 PMCID: PMC10185008 DOI: 10.4103/ijn.ijn_380_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/27/2021] [Accepted: 11/19/2021] [Indexed: 11/05/2022] Open
Abstract
Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is among the spectrum of monoclonal protein-associated renal diseases, with only about 15 case reports in children. We report a 7-year-old boy with biopsy-proven crescentic PGNMID who progressed to end-stage renal disease within a few months of presentation. He then received a renal transplant with his grandmother as a donor. Proteinuria was detected at 27 months post-transplant and an allograft biopsy revealed a recurrent disease.
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Affiliation(s)
- Nishika Madireddy
- Department of Histopathology, Apollo Hospitals, Hyderabad, Telangana, India
| | - Radhika Patil
- Department of Histopathology, Apollo Hospitals, Hyderabad, Telangana, India
| | | | - Manish C. Varma
- Department of Nephrology, Apollo Hospitals, Hyderabad, Telangana, India
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Yoshizawa N, Yamada M, Fujino M, Oda T. Nephritis-Associated Plasmin Receptor (NAPlr): An Essential Inducer of C3-Dominant Glomerular Injury and a Potential Key Diagnostic Biomarker of Infection-Related Glomerulonephritis (IRGN). Int J Mol Sci 2022; 23:ijms23179974. [PMID: 36077377 PMCID: PMC9456382 DOI: 10.3390/ijms23179974] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/11/2022] [Accepted: 08/16/2022] [Indexed: 11/25/2022] Open
Abstract
Nephritis-associated plasmin receptor (NAPlr) was originally isolated from the cytoplasmic fraction of group A Streptococci, and was found to be the same molecule as streptococcal glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and plasmin receptor (Plr) on the basis of nucleotide and amino acid sequence homology. Its main functions include GAPDH activity, plasmin-binding capacity, and direct activation of the complement alternative pathway (A-P). Plasmin trapped by deposited NAPlr triggers the degradation of extracellular matrix proteins, such as glomerular basement membranes and mesangial matrix, and the accumulation of macrophages and neutrophils, leading to the induction of plasmin-related endocapillary glomerular inflammation. Deposited NAPlr at glomerular endocapillary site directly activates the complement A-P, and the endocapillary release of complement-related anaphylatoxins, C3a and C5a, amplify the in situ endocapillary glomerular inflammation. Subsequently, circulating and in situ-formed immune complexes participate in the glomerular injury resulting in NAPlr-mediated glomerulonephritis. The disease framework of infection-related glomerulonephritis (IRGN) has been further expanded. GAPDH of various bacteria other than Streptococci have been found to react with anti-NAPlr antibodies and to possess plasmin-binding activities, allowing glomerular NAPlr and plasmin activity to be utilized as key biomarkers of IRGN.
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Affiliation(s)
| | - Muneharu Yamada
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Tokyo 193-0998, Japan
| | - Masayuki Fujino
- National Institute of Infectious Disease, Tokyo 162-8640, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Tokyo 193-0998, Japan
- Correspondence: ; Tel.: +81-42-665-5611; Fax: +81-42-665-1796
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Miller P, Xiao AY, Kung VL, Sibley RK, Higgins JP, Kambham N, Charu V, Lenihan C, Uber AM, Talley EM, Arora N, Walavalkar V, Laszik ZG, Nast CC, Troxell ML. Progression of proliferative glomerulonephritis with monoclonal IgG deposits in pediatric patients. Pediatr Nephrol 2021; 36:927-937. [PMID: 33044675 DOI: 10.1007/s00467-020-04763-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/24/2020] [Accepted: 09/07/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) is a glomerular disease defined by non-organized glomerular deposits of heavy and light chain-restricted immunoglobulin and is rarely reported in children. METHODS We characterized a series of nine pediatric patients from two academic centers with biopsy-proven PGNMID and additionally describe two patients with monotypic IgG in the setting of IgM deposition. RESULTS Each patient presented with hematuria and/or proteinuria; however, only five had elevated serum creatinine. Prodromal or concurrent infection was identified in six patients, low C3 in five, and alternate complement pathway gene variants in two. No monoclonal serum proteins were identified in five tested patients. Seven patients had monotypic deposits composed of IgG3-λ, two showed IgG3-κ, and one each IgG1 and IgG3 with lambda dominance in the setting of IgM deposition. The glomerular pattern was predominantly mesangial proliferative or membranoproliferative glomerulonephritis (MPGN). Treatment and outcomes were variable; four patients have recent PGNMID diagnoses and therefore minimal follow up, one had relatively stable kidney function for over a decade, and six experienced kidney failure, with four receiving transplants. Recurrent deposits of the same isotype were identified in five of six transplanted kidneys, corresponding to three of four transplanted patients. One of these patients developed PGNMID recurrences in three separate kidney allografts over a 20-year disease course. CONCLUSIONS Our study emphasizes the need for upfront IgG subclass investigation in pediatric mesangial or MPGN with IgG deposition and monotypic or biased light-chain staining. Furthermore, this pediatric experience suggests expanded pathogenic considerations in PGNMID. Graphical abstract.
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Affiliation(s)
- Paul Miller
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, L235, Stanford, CA, 94305, USA
| | - Andrew Y Xiao
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, L235, Stanford, CA, 94305, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Vanderlene L Kung
- Department of Pathology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Richard K Sibley
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, L235, Stanford, CA, 94305, USA
| | - John P Higgins
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, L235, Stanford, CA, 94305, USA
| | - Neeraja Kambham
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, L235, Stanford, CA, 94305, USA
| | - Vivek Charu
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, L235, Stanford, CA, 94305, USA
| | - Colin Lenihan
- Stanford Adult Kidney Transplant Program, Stanford, CA, USA
| | - Amanda M Uber
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Stanford, CA, USA
| | - Elizabeth M Talley
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Stanford, CA, USA
| | - Neiha Arora
- Department of Nephrology, The Permanente Medical Group Northern California, Oakland, CA, USA
| | - Vighnesh Walavalkar
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Zoltan G Laszik
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Cynthia C Nast
- Department of Pathology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Megan L Troxell
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, L235, Stanford, CA, 94305, USA.
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Noda S, Mandai S, Oda T, Shinoto T, Sato H, Sato K, Hirokawa K, Noda Y, Uchida S. Asymptomatic sinusitis as an origin of infection-related glomerulonephritis manifesting steroid-resistant nephrotic syndrome: A case report. Medicine (Baltimore) 2020; 99:e20572. [PMID: 32569182 PMCID: PMC7310930 DOI: 10.1097/md.0000000000020572] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Infection is a major trigger or pathogenic origin in a substantial proportion of glomerulonephritis (GN) patients, typically manifesting infection-related GN (IRGN). Various microorganisms, infection sites, and clinical and histopathological features are involved in IRGN. Once an infectious origin is identified and successfully eradicated, nephrotic syndrome or kidney dysfunction is spontaneously resolved. However, if patients are asymptomatic and the origin is undetermined, the diagnosis and treatment of GN is challenging. This case presentation reported on an IRGN case manifesting steroid-resistant nephrotic syndrome associated with asymptomatic sinusitis as a pathogenic origin. PATIENT CONCERNS A 68-year-old male presented with severe kidney dysfunction and edema in both extremities. DIAGNOSIS The patient was clinically diagnosed with hypocomplementemic nephrotic syndrome and kidney dysfunction and histopathologically with diffuse proliferative GN and a focal pattern of membranoproliferative GN. The findings suggested that idiopathic membranoproliferative glomerulonephritis type I was more likely than IRGN, given a critical lack of apparent infection. INTERVENTIONS Combined intravenous methylprednisolone, oral prednisolone, and cyclosporin did not improve the patient's condition. Thus, IRGN associated with inapparent infectious origin was suspected. Repeated thorough and careful examinations including CT scan showed sinusitis in his left maxillary sinus. Moreover, reanalysis of kidney specimen revealed positive nephritis-associated plasmin receptor in glomeruli, a typical finding for IRGN, supporting a pathogenic significance of his sinusitis. Medical treatment was initiated with 200 mg oral clarithromycin daily. OUTCOMES Oral clarithromycin gradually improved proteinuria and hypocomplementemia and resulted in nephrotic syndrome remission in parallel with opacification resolution of sinuses shown on CT. LESSONS This case presentation showed that asymptomatic sinusitis is potentially a pathogenic IRGN origin. A gold standard therapy for idiopathic GN, corticosteroid could be damaging in uncontrolled or underdiagnosed infection. In asymptomatic patients, a thorough screening of infectious diseases, including sinusitis, together with a renal histological evaluation of glomerular nephritis-associated plasmin receptor deposition is also essential in treating a wide spectrum of GN.
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Affiliation(s)
- Shohei Noda
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
| | - Shintaro Mandai
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Tokyo Medical University Hachioji Medical Center, Hachioji
| | - Tomoko Shinoto
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
| | - Hidehiko Sato
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
| | - Keiko Sato
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
| | - Katsuiku Hirokawa
- Department of Clinical Pathology, Nitobe Memorial Nakano General Hospital, Nakano, Tokyo, Japan
| | - Yumi Noda
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
| | - Shinichi Uchida
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo
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Glomerular Deposition of Nephritis-Associated Plasmin Receptor (NAPlr) and Related Plasmin Activity: Key Diagnostic Biomarkers of Bacterial Infection-related Glomerulonephritis. Int J Mol Sci 2020; 21:ijms21072595. [PMID: 32276523 PMCID: PMC7178002 DOI: 10.3390/ijms21072595] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023] Open
Abstract
It is widely known that glomerulonephritis (GN) often develops after the curing of an infection, a typical example of which is GN in children following streptococcal infections (poststreptococcal acute glomerulonephritis; PSAGN). On the other hand, the term “infection-related glomerulonephritis (IRGN)” has recently been proposed, because infections are usually ongoing at the time of GN onset in adult patients, particularly in older patients with comorbidities. However, there has been no specific diagnostic biomarker for IRGN, and diagnosis is based on the collection of several clinical and pathological findings and the exclusion of differential diagnoses. Nephritis-associated plasmin receptor (NAPlr) was originally isolated from the cytoplasmic fraction of group A streptococcus as a candidate nephritogenic protein for PSAGN and was found to be the same molecule as streptococcal glyceraldehyde-3-phosphate dehydrogenase and plasmin receptor. NAPlr deposition and related plasmin activity were observed with a similar distribution pattern in the glomeruli of patients with PSAGN. However, glomerular NAPlr deposition and plasmin activity could be observed not only in patients with PSAGN but also in patients with other glomerular diseases, in whom a preceding streptococcal infection was suggested. Furthermore, such glomerular staining patterns have been demonstrated in patients with IRGN induced by bacteria other than streptococci. This review discusses the recent advances in our understanding of the pathogenesis of bacterial IRGN, which is characterized by NAPlr and plasmin as key biomarkers.
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Proliferative glomerulonephritis with monoclonal immunoglobulin G deposits is associated with high rate of early recurrence in the allograft. Kidney Int 2018; 94:159-169. [PMID: 29716794 DOI: 10.1016/j.kint.2018.01.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/03/2018] [Accepted: 01/18/2018] [Indexed: 11/20/2022]
Abstract
The characteristics of allograft proliferative glomerulonephritis with monoclonal immunoglobulin G deposits (PGNMID) are not well defined. To better characterize this disease we retrospectively identified 26 patients with allograft PGNMID, including 16 followed with early protocol biopsies. PGNMID was found to be a recurrent disease in most (89%) patients. A diagnostic biopsy was done for proteinuria and/or increased creatinine in most patients. Median time from transplant to diagnostic biopsy was 5.5 months, with detection within three to four months post-transplant in 86% of patients. Mesangial proliferative glomerulonephritis was the most common pattern on the diagnostic biopsy with 89% of cases showing immunoglobulin G3 subtype restriction. A detectable serum paraprotein was present in 20% of patients. During a mean follow up of 87 months from implantation, 11 of 25 patients lost their allograft largely due to PGNMID within a mean of 36 months from diagnosis. Median graft survival was 92 months. Independent predictors of graft loss were a higher degree of peak proteinuria and longer time from implantation to diagnosis. Sixteen patients were treated with immunosuppressive therapy which resulted in over 50% reduction in proteinuria in 60%, and improvement of glomerular pathology in nine of 13 patients. However, 44% of responders subsequently relapsed. Thus, PGNMID has a high recurrence rate in renal allografts occurring early with detection enhanced by protocol biopsies. Graft outcome is guarded as nearly half of patients lose their graft within three years from diagnosis. Hence, there is a need for better treatment strategies for this disease.
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