title: Chronic graft-versus-host disease of the kidney in patients with allogenic hematopoietic stem cell transplant.
abstract: BACKGROUND
  Allogenic hematopoietic stem cell transplant (allo-HSCT) is the treatment of choice for several hematological diseases. Although rare, patients could present nephrotic syndrome as a clinical feature of chronic graft-versus-host disease (cGVHD). The objective of our study is to screen patients with allo-HSCT to determine who developed a glomerular pathology in the context of cGVHD.
  
  
  METHODS
  We studied patients who underwent allo-HSCT treatment in our center between October 1995 and October 2012 and who developed glomerular pathology. cGVHD was defined as a pathology when it appeared after 100 d post-allo-HSCT.
  
  
  RESULTS
  Five hundred eighty-three allo-HSCT were performed. The prevalence of cGVHD of the kidney was 1.03%. All patients with cGVHD of the kidney were hosts who received peripheral blood from an identical HLA match donor. GVHD prophylaxis with calcineurin inhibitors plus methotrexate was administered in five cases, and prophylaxis with sirolimus was used in another case. cGVHD of the kidney was seen to appear after the removal of the prophylaxis for GVHD, within 33 ± 11.54 months intervals after allo-HSCT in five patients and in another patient, it appeared despite immunosuppressive therapy being administered. All patients had proteinuria, within 11.82 ± 9.03 g/d ranges. The kidney biopsies revealed membranous glomerulonephritis (four patients), focal segmental glomerulonephritis (one patient) and lupus nephropathy class III (one patient). It seems, immunosuppressive therapy achieved complete remission, within the first year of treatment in four patients. Although in three of them, the proteinuria recurred when we tried to remove the therapy; two patients have recently started treatment, being in partial remission now.
  
  
  CONCLUSIONS
  cGVHD of the kidney is a rare complication after allo-HSCT, related with the removal of the immunosuppression. Monitoring proteinuria in these patients may be useful. In our patients, a complete remission was achieved; although the removal of the immunosuppression may lead to the appearance of outbreaks. We must reconsider the treatment of glomerular pathology secondary to cGVHD.
authors.affiliation: Service of Nephrology, University Hospital of Salamanca, Salamanca, Spain. pilarfg@usal.es
authors.forename: Pilar
authors.initials: P
authors.lastname: Fraile
authors.affiliation: Service of Nephrology, University Hospital of Salamanca, Salamanca, Spain. pilarfg@usal.es
authors.forename: Fraile
authors.initials: F
authors.lastname: Pilar
authors.forename: Lourdes
authors.initials: L
authors.lastname: Vazquez
authors.forename: Vazquez
authors.initials: V
authors.lastname: Lourdes
authors.forename: Dolores
authors.initials: D
authors.lastname: Caballero
authors.forename: Caballero
authors.initials: C
authors.lastname: Dolores
authors.forename: Pedro
authors.initials: P
authors.lastname: Garcia-Cosmes
authors.forename: Garcia-Cosmes
authors.initials: GC
authors.lastname: Pedro
authors.forename: Lucia
authors.initials: L
authors.lastname: López
authors.forename: López
authors.initials: L
authors.lastname: Lucia
authors.forename: Jesus
authors.initials: J
authors.lastname: San Miguel
authors.forename: San Miguel
authors.initials: SM
authors.lastname: Jesus
authors.forename: Jose Matias
authors.initials: JM
authors.lastname: Tabernero
authors.forename: Tabernero
authors.initials: T
authors.lastname: Jose Matias
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease; D005260:Female; D006086:Graft vs Host Disease / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D018380:Hematopoietic Stem Cell Transplantation / Q000009:adverse effects*; D006801:Humans; D007223:Infant; D007674:Kidney Diseases / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D007678:Kidney Glomerulus / Q000473:pathology; D008297:Male; D008875:Middle Aged; D011507:Proteinuria / Q000175:diagnosis; D012189:Retrospective Studies; D014184:Transplantation, Homologous; D016896:Treatment Outcome; D055815:Young Adult
keywords: acute graft-versus-host disease; allogenic hematopoietic stem cell transplant; chronic graft-versus-host disease; immunosuppression; nephrotic syndrome