A Case of De Novo Membranous Nephropathy Causing Renal Transplant Rejection

Abstract

We present a novel case of de novo membranous nephropathy (DNMN) leading to transplant rejection in a 51-year-old female patient. The patient has a transplant history of two renal transplants for end-stage renal disease due to lupus nephritis. She had a prior unrelated, living donor kidney transplant that was subsequently replaced by a deceased donor kidney transplant due to graft failure. This patient's case is intriguing because DNMN is a rare cause of transplant rejection, and the literature demonstrates a scarcity of clinical examples. Interestingly, post-transplant DNMN has been suggested to be a separate disease from recurrent post-transplant MN and is associated with separate risk factors and diagnostic findings. As DNMN is considered a manifestation of antibody-mediated rejection, it should be treated with immunosuppressive therapy. As such, the presented case has received immunosuppressive therapy. In addition, DNMN is associated with humoral alloimmunity. Potentially other inflammatory processes (such as infection/potential UTI in our patient's case) could cause exposure to undetectable donor antigens on renal transplants leading to antibody-mediated rejection via DNMN.

How to Choose the Right Treatment for Membranous Nephropathy

“…However, recurrent membranous nephropathy (RMN) can occur in up to 40% of cases, while DNMN is reported in up to 2% in the adult population and up to 9% in the pediatric population [137]. Of note, the latter is more frequent in patients with HCV infection [138], CMV infection [139] Alport syndrome or kidney obstruction or in association with IgA nephropathy [140]. Moreover, the risk of MN recurrence is even higher in the case of a second transplant [141] and correlates with the anti-PLA2R antibodies titer [142].…”