Kidney Week

Abstract: PUB532

Recurrent Lupus Nephritis in a Kidney Transplant Patient

Session Information

• Publication Only

Category: Transplantation

• 2102 Transplantation: Clinical

Authors

• Sajjad, Ahsan, Prolato Clinical Research Center, Houston, Texas, United States

Ahsan Sajjad, MD

• Amer, Rida, Prolato Clinical Research Center, Houston, Texas, United States

Rida Amer, MD

• Tchakarov, Amanda, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, United States

Amanda Tchakarov, MD

• Mandayam, Sreedhar A., The University of Texas MD Anderson Cancer Center Anne C Brooks Brain and Spine Center, Houston, Texas, United States

Sreedhar A. Mandayam, MD, FASN, MBA, MPH

• Butt, Muhammad Daoud, Universiti Malaya Faculty of Medicine, Kuala Lumpur, Wilayah Persekutuan, Malaysia

Muhammad Daoud Butt, PhD

Introduction

Lupus nephritis (LN) is a severe manifestation of SLE. The recurrence of LN post-renal transplantation is an uncommon event, particularly in patients without a prior diagnosis of SLE.

Case Description

A 60-year-old female with a history of CKD due to IgA nephritis underwent renal transplantation in 1999. In 2023, she presented with worsening proteinuria, lacrimal gland enlargement, Jaccoud's arthropathy, and b/l lower extremities pitting edema. Renal allograft biopsy revealed diffuse lupus nephritis ISN/RPS Class IV, 19% global sclerosis of glomeruli, and 20% interstitial fibrosis with tubular atrophy. CKD onset followed a miscarriage in 1997, progressing to end-stage renal failure during a subsequent pregnancy in 1998, necessitating transplantation. Absence of prior SLE diagnosis and prolonged immunosuppression (Cellcept and Cyclosporine) suggest undiagnosed chronic SLE, possibly reactivated or newly manifested as LN in the allograft.
Biopsy shows immune complex-mediated glomerulonephritis with endocapillary hypercellularity, neutrophils and a few wire-loops/hyaline thrombi. By immunofluorescence, there is positivity for IgA, IgG, IgM C3, C1q, kappa and lambd. Corresponding mesangial and subendothelial electron-dense deposit are present ultrastructurally.
Diagnosis:
Immune complex-mediated glomerulonephritis, Findings consistent with borderline changes of T-Cell mediated rejection per Banff criteria. Severe Interstitial inflammation(i3) and Mild tubulitis(t1). Peritubular capillaries were focally positive for C4d by immunohistochemistry. Moderate arterial and hyaline arteriolar sclerosis. Global sclerosis of 19%(3/16) of glomeruli and approximately 20% interstitial fibrosis with tubular atrophy

Discussion

Lupus nephritis is found in approximately 30-50% of SLE patients, with recurrence post-transplantation being rare, occurring in about 1-2% of cases. This case underscores the diagnostic challenge and the necessity of considering SLE in patients with renal allografts presenting with proteinuria. The long-term immunosuppressive therapy may have masked the underlying SLE, delaying the diagnosis until the renal allograft biopsy revealed lupus nephritis.