Outcomes of Kidney Transplants with Donor-Derived Proliferative Glomerulonephritis with Monoclonal Immunoglobulin Deposits

Introduction: Donor-derived proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is exceptionally rare. Here we present the outcomes of two recipients who received mate kidneys which revealed PGNMID in the allograft day 0 biopsies. Case Description: The donor was a 60-year-old Hispanic male who sustained a fatal head injury. Terminal creatinine was 1.94 g/dl, albumin 1.8 g/dL, and urinalysis showed 1+ protein, 2+ blood. Preimplantation biopsies of both kidneys showed 0-9% global glomerulosclerosis and <5% interstitial fibrosis and tubular atrophy. Both recipients (Patient A and B) had ESRD from type 2 diabetes and received basiliximab induction with mycophenolate, tacrolimus, and steroid maintenance. Both had delayed graft function until 3 weeks post-transplant. Day 0 allograft biopsies showed mesangial proliferative glomerulonephritis (Figure 1A) and mesangial granular staining for IgG and kappa on immunofluorescence (IF) (Figure 1B). Both patients had negative paraproteinemia workup. Persistent mesangial proliferation with segmental scars and IgG deposits were seen at 4-month biopsies (Figure 1C). IgG subclass IF confirmed monotypic IgG2 deposits. Only segmental scars were present without IgG deposits at 1 year (Figure 1D). Patient A had a baseline serum creatinine of 1.1-1.3 mg/dL and patient B with creatinine of 2.0-2.4 mg/dL at 1 year. Discussion: These cases represent the first report of donor-derived PGNMID. Only recurrence or de novo cases of PGNMID were reported with guarded outcomes in kidney transplants.[1-4] Neither recipient required targeted treatment for monoclonal gammopathy with resolution of IgG deposits at one year. These findings suggest donor-derived PGNMID may not preclude successful transplantation and have favorable kidney function.