title: Proliferative glomerulonephritis with monoclonal immunoglobulin G deposits complicated by immunoglobulin A nephropathy in the renal allograft.
abstract: Immunoglobulin (Ig) A nephropathy (IgAN) is a known autoimmune disease due to abnormal glycosylation of IgA1, and occasionally, IgG co-deposition occurs. The prognosis of IgG co-deposition with IgAN is adverse, as shown in the previous studies. However, in the clinical setting, monoclonality of IgG co-deposition with IgAN has not been observed. We describe a case of proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) combined with IgAN in a renal allograft. A-21-year-old man developed end-stage renal failure with unknown aetiology and underwent living-donor kidney transplantation from his mother 2 years after being diagnosed. One year after kidney transplantation, proteinuria 2+ and haematuria 2+ were detected; allograft biopsy revealed mesangial IgA and C3 deposits, indicating a diagnosis of IgAN. After tonsillectomy and steroid pulse therapy, proteinuria and haematuria resolved. However, 4 years after transplantation, pedal oedema, proteinuria (6.89 g/day) and allograft dysfunction (serum creatinine (sCr) 203.3 µmol/L) appeared. A second allograft biopsy showed mesangial expansion and focal segmental proliferative endocapillary lesions with IgA1λ and monoclonal IgG1κ depositions. Electron microscopic analysis revealed a massive amount of deposits, located in the mesangial and subendothelial lesions. A diagnosis of PGNMID complicated with IgAN was made, and rituximab and plasmapheresis were added to steroid pulse therapy. With this treatment, proteinuria was alleviated to 0.5 g/day, and the allograft dysfunction recovered to sCr 132.6 µmol/L. This case suggests a necessity for investigation of PGNMID and IgA nephropathy in renal allografts to detect monoclonal Ig deposition disease.
authors.affiliation: Department of Surgical Pathology, Tokyo, Japan.|Department of Medicine, Tokyo, Japan.
authors.forename: Anri
authors.initials: A
authors.lastname: Sawada
authors.affiliation: Department of Surgical Pathology, Tokyo, Japan.
authors.forename: Kunio
authors.initials: K
authors.lastname: Kawanishi
authors.affiliation: Division of Pathology, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan.
authors.forename: Shigeru
authors.initials: S
authors.lastname: Horita
authors.affiliation: Department of Pathology, Kawasaki Municipal Tama Hospital, Kawasaki, Kanagawa, Japan.
authors.forename: Junki
authors.initials: J
authors.lastname: Koike
authors.affiliation: Department of Anatomy, Showa University School of Medicine, Tokyo, Japan.
authors.forename: Kazuho
authors.initials: K
authors.lastname: Honda
authors.affiliation: Department of Medicine, Tokyo, Japan.
authors.forename: Ayami
authors.initials: A
authors.lastname: Ochi
authors.affiliation: Department of Medicine, Tokyo, Japan.
authors.forename: Mizuki
authors.initials: M
authors.lastname: Komoda
authors.affiliation: Department of Medicine, Tokyo, Japan.
authors.forename: Yoichiro
authors.initials: Y
authors.lastname: Tanaka
authors.affiliation: Department of Medicine, Tokyo, Japan.
authors.forename: Kohei
authors.initials: K
authors.lastname: Unagami
authors.affiliation: Department of Urology, Tokyo, Japan.
authors.forename: Masayoshi
authors.initials: M
authors.lastname: Okumi
authors.affiliation: Department of Urology, Tokyo, Japan.
authors.forename: Tomokazu
authors.initials: T
authors.lastname: Shimizu
authors.affiliation: Department of Urology, Tokyo, Japan.
authors.forename: Hideki
authors.initials: H
authors.lastname: Ishida
authors.affiliation: Department of Urology, Tokyo, Japan.
authors.forename: Kazunari
authors.initials: K
authors.lastname: Tanabe
authors.affiliation: Department of Surgical Pathology, Tokyo, Japan.
authors.forename: Yoji
authors.initials: Y
authors.lastname: Nagashima
authors.affiliation: Department of Medicine, Tokyo, Japan.
authors.forename: Kosaku
authors.initials: K
authors.lastname: Nitta
mesh_terms: D064591:Allografts; D000911:Antibodies, Monoclonal / Q000032:analysis*; D001706:Biopsy; D003176:Complement C3 / Q000032:analysis; D005455:Fluorescent Antibody Technique; D005922:Glomerulonephritis, IGA / Q000175:diagnosis / Q000276:immunology* / Q000628:therapy; D015432:Glomerulonephritis, Membranoproliferative / Q000175:diagnosis / Q000276:immunology* / Q000628:therapy; D005923:Glomerulosclerosis, Focal Segmental / Q000175:diagnosis / Q000276:immunology* / Q000628:therapy; D006417:Hematuria / Q000209:etiology; D006801:Humans; D007070:Immunoglobulin A / Q000032:analysis*; D007074:Immunoglobulin G / Q000032:analysis*; D007145:Immunoglobulin kappa-Chains / Q000032:analysis*; D007678:Kidney Glomerulus / Q000276:immunology* / Q000648:ultrastructure; D016030:Kidney Transplantation / Q000009:adverse effects*; D019520:Living Donors; D008297:Male; D008854:Microscopy, Electron; D010956:Plasmapheresis; D011507:Proteinuria / Q000209:etiology; D020551:Pulse Therapy, Drug; D000069283:Rituximab / Q000627:therapeutic use; D013256:Steroids / Q000008:administration & dosage; D013997:Time Factors; D014068:Tonsillectomy; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000911:Antibodies, Monoclonal; C038245:C3 protein, human; D003176:Complement C3; D007070:Immunoglobulin A; D007074:Immunoglobulin G; D007145:Immunoglobulin kappa-Chains; D013256:Steroids; D000069283:Rituximab
keywords: Immunoglobulin A nephropathy; biclonal immunoglobulin deposition disease; kidney transplantation; proliferative glomerulonephritis with monoclonal IgG deposit; rituximab