Changing the Tides in Hawaii: Recurrent IgA Nephropathy in an Isograft on the 70th Anniversary of the First Successful Twin Transplantation

Introduction: IgA nephropathy (IgAN) is the most common primary glomerulopathy globally and also most common to recur after transplantation. While a pediatric screening program for IgAN is not standard in the United States, it is routine in several Asian countries. We report a case of presumed recurrent IgAN in a monozygotic twin and question the status quo for screening in Hawaii. Case Description: A 36-year-old Asian male with history of living related renal transplant (LRRT) from twin brother underwent allograft biopsy for increasing proteinuria and hematuria. Serum creatinine (SCr) and eGFR were stable (Chart 1). Four years prior he presented to his PCP with tension headaches and found hypertensive 191/99 mmHg, SCr 6.0 mg/dL with eGFR 11 mL/min/1.73m(2). His brother was confirmed as a monozygous twin without hypertension, proteinuria or hematuria. LRRT was performed 18 months after initial presentation. He received basiliximab induction and tacrolimus with immediate graft function and discharged on post op day 4. One year post transplant immunosuppression was weaned off. The allograft biopsy showed no evidence of acute cellular or antibody-mediated rejection but was consistent with recurrent IgAN (MEST-C score M1, E0, S0, T0, C0). Mycophenolate mofetil was started with decrease in proteinuria. Two years post donation his brother continued without proteinuria or hematuria. Discussion: In 1954, the first twin transplantation or "isograft" was considered a success after 8 year graft survival. Yet, in the following 70 years there remain uncertainties about prevention of recurrent disease, especially IgAN. Our case exemplifies the need for earlier detection and prevention of end stage kidney disease in early adulthood. Further studies are warranted in a high multi-ethnic Asian population like Hawaii to assess the benefit of a screening program for IgAN. Chart 1 - Events Months ACR mg/g creatinine Serum Creatinine mg/dL eGFR mL/min/1.73m(2) Urine RBC RT DT RT DT RT DT RT Pre-op -2 12.8 0.8 5 117 0 1.2 1.7 72 60 6 <7.8 1.2 1.3 81 74 12 None 1.1 1.0 90 101 0-2 24 28.6 1.1 1.5 90 62 3-5 28 117.9 1.1 89 6-20 Bx 30 1.2 80 MMF 500mg BID 34 103.8 1.0 100 0-2