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De Novo Immune Complex-Mediated Glomerulonephritis Post Transplantation

A case study on a kidney transplant recipient who developed glomerulonephritis after switching from cyclosporine to rapamycin, showcasing the importance of immunosuppression management. Explore differential diagnosis, clinical course, and potential treatment options.

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De Novo Immune Complex-Mediated Glomerulonephritis Post Transplantation

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  1. Slide SeminarDrugs and KidneyCase 3 Heinz Regele Department of Pathology

  2. Clinical history • First renal transplant lost in 1995 due to infectious complications 4 weeks after TX • Second allograft in October 1999. During the first post-transplantation year serum creatinine (sCr) ranged from 2.2-2.5 mg/dl (194-221 μmol/l). • Maintenance immunosuppression: Cy-A, MMF, and low-dose steroids mg/day). • Fourteen months after TX recruitment to a clinical trial of cyclosporine withdrawal in patients with chronic allograft dysfunction. Conversion to rapamycin was performed after ruling out rejection or glomerular disease (protocol biopsy). • After 9 months of rapamycin therapy (12- 20 ng/ml), sCr increased from 2.5 mg/dl to 4.0 mg/dl (221-354 μmol/l), and proteinuria of 2.5 g/ 24 h developed.

  3. Differential diagnosis Chronic TX Glomerulopathy Immune complex mediated GN Thrombotic microangiopathy

  4. C4d

  5. C4d C3

  6. C4d C4d C4d

  7. Diagnosis • De novo IC mediated Glomerulonephritis (likely related to the switch from CNI to rapamycin) • No convincing evidence of acute rejection (C4d negative) • Medullary only mononuclear inflammatory infiltrate

  8. IC GN after rapamycin switch MGN IgA-GN IgA-GN

  9. Clinical course Dittrich E, Transpl Int 2004

  10. C4d

  11. Evidence for pro-inflammatory properties of rapamycin Recurrent or de-novo GN develops in allografts after conversion to sirolimus and recovery can be achieved by re-introducing of CNI Säemann MD, AJT 2009

  12. Immunosuppression and transplant glomerulonephritis The likelihood of developing a recurrent GN was not associated with a specific type of immunosuppressive regimen A USRDS analysis of 41272 transplant recipients found recurrent GN causing graft loss in 2,6% of patients Any change of immunosuppression however increased the risk of developing recurrent GN Mulay AV, AJT 2009

  13. Evidence for pro-inflammatory properties of rapamycin Recurrent or de-novo GN in allografts after conversion to sirolimus and recovery after re-introduction of CNI Drug dependent occurrence of fever and inflammation (unrelated to infection) in different organs Sirolimus treatment leads to exacerbation of lesions in some experimental models of autoimmune disease. Säemann MD, AJT 2009

  14. Different effects of rapamycin in innate and adaptive immunity Säemann MD, AJT 2009

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