Rapid deterioration of graft function in kidney transplant from the donor with diffuse proliferative lupus nephritis with thrombotic microangiopathy

초록

(Introduction) In the era of donor shortage, using kidneys from marginal donors has significantly increased. There were a couple cases which reported a successful renal transplant from a deceased donor with diffuse proliferative lupus nephritis (DPLN). Here, we report rapidly deteriorating graft function in a kidney transplant from the donor with a history of systemic lupus erythematous (SLE) whose time zero biopsy revealed DPLN and thrombotic microangiopathy (TMA). (Methods) Two patients underwent deceased kidney transplant from a donor with a history of SLE. The clinical and pathological outcomes were analyzed. (Results) Donor’s initial serum creatinine was 1.2mg/dL and proteinuria was one positive. Creatinine level went up to 4.4 mg/ dL during the donor management, with urine output maintained about 50 or 100ml/hr. Kidney transplants for both recipient were done uneventfully. On the first postoperative day, the time zero biopsy results were reported as diffuse proliferative lupus nephritis with thrombotic microangiopathy (TMA). It also had acute antibody mediated rejection (AMR) mimic findings which included intimal arteritis (v3), peritubular capillaritis (ptc 2) and C3d positive. Both recipients’ creatinine levels were not improved and hemodialysis was started a couple days after transplant. The serial biopsies showed continuously worsening vasculitis and inflammation. The interstitial fibrosis was rapidly progressed within a month after transplant. (Conclusion) There has been a couple reports which describe the successful renal transplantation from a donor with diffuse proliferative lupus nephritis. However, if the potential deceased kidney donor with a history of lupus nephritis shows TMA features, especially with the time zero biopsy-proven TMA, the kidney transplant should be avoided.