When the Donor Surprises You: A Case Report

The possibility of transplanting a graft from a cadaveric donor with unknown membranous nephropathy (MN) has been described in the literature. We present the case of 2 patients who received their first kidney transplant (KT) from a 27-year-old male donor with no relevant medical history. The first recipient was a 50-year-old man with stage 5 chronic kidney disease secondary to diabetic kidney disease. Two biopsies were performed; the first was performed on day +9 because of impaired renal function coinciding with high levels of tacrolimus, and vacuolization of the arteriolar walls was observed with no other findings; the second was performed on day +13 because of creatinine stagnation, and methenamine silver staining showed multiple cavities and isolated spikes. Immunofluorescence revealed contiguous granular positivity in capillary walls for IgG and C4d, and immunohistochemistry showed contiguous parietal positivity for IgG4, compatible with donor membranous glomerulopathy. Anti–phospholipase-2 receptor (PLA2R) antibodies were negative. The second-year biopsy showed persistence of stage 1 MN, without proteinuria. The second recipient was a 38-year-old man with hypertension and unknown stage 5 chronic kidney disease who experienced immediate kidney function post-KT. In the protocol kidney biopsy 3 months post-KT, data consistent with stage 1 membranous glomerulopathy were also observed. Anti-PLA2R antibodies were negative, and proteinuria did not increase. The second-year protocol biopsy showed no MN data.