Heavy Proteinuria as a Manifestation of Acute Allograft Rejection Presenting Early after Kidney Transplantation: A Retrospective, Single- Center Case Series

Abstract : The differential diagnosis of heavy proteinuria presenting early after kidney transplantation has generally included de novo or recurrent glomerulonephritis (GN), whereas proteinuria is thought to be an unusual presentation of acute allograft rejection. We retrospectively analyzed the characteristics of 7 patients who presented with early (median 9 days post-transplant) heavy proteinuria with or without renal failure, in association with the development of new donor anti-HLA antibody. End Stage Renal Disease (ESRD) was due to primary GN in three patients. Mean proteinuria at presentation was 7.46 ? 2.44 gm/24 hours. Donor specific anti-HLA antibody was associated with each episode. Diffuse peritubular C4d staining was noted in three cases. Response to therapy with intravenous immunoglobulin G (IVIg) was good, with mean creatinine of 1.48 ? 0.13 mg% at last follow-up of 2-78 months with resolution of proteinuria, and no graft loss. Based on this series, we recommend screening for proteinuria post transplant in all allograft recipients, not only to detect de-novo or recurrent GN in the allograft, but also to detect antibody mediated rejection.