ISRTPCON 2013

Lt Col Rohit TewariDept of PathologyArmed Forces Medical CollegePune

Age- 55 yrsSex- MaleKnown hypertensive and diabetic (5 yrs)Presented with rapid deterioration of

renal functionS Cr 1.6 mg% to 7.5 mg% over 4

months. Urine examination-

◦Alb 2+◦8-10 pus cells◦25-30 RBC

S-9077-10

IgG IgG

C3 C1Q

Kappa Lambda

Proliferative Glomerulonephritis, Suggestion of Lupus nephritis

All serological tests done subsequently for SLE- Neg

Renal function progressively worsened over the next one and a half year.

Taken up for Live unrelated renal allograft transplant, standard immunosuppression.

Immediate post transplant period – uneventful.

Baseline S Cr 1.1-1.2

Brain abscess after 2 months. Mycophenolate stopped.

S Cr 2.3 gm%.Acute graft rejection suspected.

Biopsy

S-11235-12

IgG

C3 C1Q

Kappa Lambda

IgG1 IgG2

IgG3 IgG4

Proliferative glomerulonephritis with monoclonal immunoglobulin deposits. (PGNMID)

Work up for myeloma- initially neg, 2 mths later- M band

Recurrent or denovo?

kappa Lambda

IgG1 IgG2

iIgG3 IgG4

FINAL DIAGNOSIS◦Proliferative glomerulonephritis with

monoclonal immunoglobulin deposits.

◦Recurrence in renal allograft.Follow upAutologous Stem cell transplantDoing well

reduction in proteinuria

.Kidney International, Vol. 65 (2004), pp. 85–96Proliferative glomerulonephritis with monoclonal IgG deposits:A distinct entity mimicking immune-complex glomerulonephritisSAMIH H. NASR, GLEN S. MARKOWITZ, M. BARRY STOKES, SURYA V. SESHAN, ELSA VALDERRAMA,GERALD B. APPEL, PIERRE AUCOUTURIER, and VIVETTE D. D’AGATIDepartment of Pathology and Department of Medicine, Columbia University, College of Physicians and Surgeons, New York,New York; Department of Pathology, Weill Medical College of Cornell University, New York, New York; Department of Pathology,

Ten cases described.

Proteinuria in 100%Renal insufficiency in 80%Microhematuria in 60%Monoclonal serum/urinary protein

identified in 50%None had evidence of a

myeloma/ B cell lymphoproliferative disorder

No data on outcome/followup

NDT Plus (2010) 3: 357–359doi: 10.1093/ndtplus/sfq076Advance Access publication 2 May 2010Case ReportSteroid-responsive nephrotic syndrome in a patient with proliferativeglomerulonephritis with monoclonal IgG deposits with pure mesangialproliferative featuresAtsushi

One patient who had denovo disease in the allograft

One patient had recurrent disease 1 yr after transplant

1503 Proliferative Glomerulonephritis with Monoclonal IgG DepositsRecurs or May Develop De Novo in Renal AllograftsA Albawardi, A Satoskar, S Brodsky, GM Nadasdy, T Nadasdy. The Ohio State University,

Why this case is presented?Rarity of the conditionEarly recurrence in the renal

allograft Importance of routinely

performing kappa and lambda in renal biopsy.

Possibility of initial negativity of myeloma workup.

Recognizing and interpreting linear accentuation in diabetes.