title: Bortezomib as a Novel Approach to Early Recurrent Membranous Glomerulonephritis After Kidney Transplant Refractory to Combined Conventional Rituximab Therapy.
abstract: We report a case of early recurrent membranous glomerulonephritis after kidney transplant from a deceased donor. The patient received induction therapy and was discharged with a serum creatinine level of 0.78 mg/dL on triple maintenance immunosuppressive therapy, which included tacrolimus, mycophenolate mofetil, and prednisone. At 7 months after transplant, a graft biopsy for new-onset isolated proteinuria (2.7 g/day) revealed stage 2 recurrent membranous glomerulonephritis. In the face of persistent proteinuria despite combined conservative rituximab therapy over several months and the total eradication of CD20-positive cells, bortezomib was introduced. This resulted in a substantial decline in proteinuria within 2 months and its subsequent disappearance several months later. This was paralleled by a considerable drop in plasma CD34-positive and CD138-positive cell counts. These preliminary observations indicate that recurrent posttransplant membranous glomerulonephritis is associated in part with a B-cell- mediated immunologic process that may involve both CD20-positive and plasma cells. Rituximab-resistant or partially responsive recurrent posttransplant membranous glomerulonephritis may benefit from a proteasome inhibitor-based therapy.
authors.affiliation: From the Rafik Hariri University Hospital, Beirut, Lebanon.
authors.forename: Antoine
authors.initials: A
authors.lastname: Barbari
authors.forename: Rima
authors.initials: R
authors.lastname: Chehadi
authors.forename: Hala
authors.initials: H
authors.lastname: Kfoury Assouf
authors.forename: Gaby
authors.initials: G
authors.lastname: Kamel
authors.forename: Mahassen
authors.initials: M
authors.lastname: Jaafar
authors.forename: Ayman
authors.initials: A
authors.lastname: Abdallah
authors.forename: Sylvana
authors.initials: S
authors.lastname: Rizk
authors.forename: Marwan
authors.initials: M
authors.lastname: Masri
mesh_terms: D001706:Biopsy; D000069286:Bortezomib / Q000627:therapeutic use*; D004351:Drug Resistance; D057915:Drug Substitution; D004359:Drug Therapy, Combination; D005455:Fluorescent Antibody Technique; D015433:Glomerulonephritis, Membranous / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D007668:Kidney / Q000187:drug effects* / Q000276:immunology / Q000648:ultrastructure; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000276:immunology / Q000601:surgery*; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D008854:Microscopy, Electron; D008875:Middle Aged; D012008:Recurrence; D012074:Remission Induction; D000069283:Rituximab / Q000009:adverse effects / Q000627:therapeutic use*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D007166:Immunosuppressive Agents; D000069283:Rituximab; D000069286:Bortezomib