Successful Use of Plasma Exchange to Prevent Recurrence of C3 Glomerulonephritis after Kidney Transplantation: A Case Report

Abstract

Background: Complement-mediated glomerulonephritis relapses in about 80% of patients with a history of disease recurrence in a previous graft. There is so far no efficient treatment to prevent recurrence. Methods: Case report on the use of intermittent plasma exchange to prevent recurrence of C3 glomerulonephritis (C3GN) in a second kidney transplant, after loss of a previous graft due to disease recurrence. Results: Our 26 year-old patient was initially diagnosed with type 1 membranoproliferative glomerulonephritis with isolated C3 deposits. She developed end stage renal disease and received a first kidney transplant in 2007. The post-transplant course was complicated by an early graft loss due to biopsy proven recurrence of C3GN (after 9 months). Persistent activation of the alternative complement pathway (low C3, high C3d and normal C4) was noted before, during and after transplantation. Thus far no underlying pathogenic mechanism has been found despite extensive evaluation of the complement pathway. Because of specific anti-HLA antibodies against more than 85% of the donor panel the patient was admitted to the Eurotransplant Acceptable Mismatch program. A second kidney transplantation was performed in January 2011. We combined standard triple immunosuppression with plasma exchange (40mL/kg body weight per treatment) at decreasing frequency, with a maintenance schedule of 1 exchange every two weeks after the first month. One year after transplantation no rejection has occurred and the patient maintains good graft function (creatinine 1.3 mg/dL) without signs of complement activation, microscopic hematuria and proteinuria. A protocol biopsy 3 months after transplantation showed no signs of disease recurrence on immunofluorescence and electron microscopy. Conclusion: Prophylactic plasma exchange might correct the underlying pathogenic mechanism in patients with C3 glomerulonephritis, thereby preventing uncontrolled complement activation and recurrence of disease after kidney transplantation. Plasma exchange could be a cost-effective and widely available alternative to the recently developed C5 inhibitor Eculizimab in this indication.