Successful Renal Outcome in Membranoproliferative Glomerulonephritis Following Treatment of the Underlying Subtle Clone: A Case Report Ritika Rana, MBBS,

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Successful Renal Outcome in Membranoproliferative Glomerulonephritis Following Treatment of the Underlying Subtle Clone: A Case Report Ritika Rana, MBBS, MRCP, Paul Cockwell, MB BCh, FRCP, PhD, Bindu Vydianath, MBBS, FRCPath, Mark Cook, MB ChB, PhD, Guy Pratt, FRCP, FRCPath, MD, Mark Trehane Drayson, FRCPath, PhD, Jennifer Helen Pinney, BM BS, MD Mayo Clinic Proceedings: Innovations, Quality & Outcomes Volume 2, Issue 3, Pages 297-302 (September 2018) DOI: 10.1016/j.mayocpiqo.2018.04.003 Copyright © 2018 Terms and Conditions

Figure 1 Pathology of membranoproliferative glomerulonephritis with monoclonal IgG deposits. A-C, First biopsy. A, Glomeruli exhibit diffuse accentuation of the nodular pattern, with mesangial matrix expansion (hematoxylin-eosin, ×200). B, Silver stain, showing thickening of the membranes with double contours and endocapillary proliferation. C, Immunohistochemistry highlights faint IgG in the peripheral capillary loops. D-G, Second biopsy. D, Hypercellular glomerulus with nodular mesangial expansion, endocapillary proliferation, thickening of glomerular basement membranes and double contours (hematoxylin-eosin, ×200). E, On silver staining, double contours of the GBMs and mesangial deposits are seen. F, Electron microscopy showing marked expansion of the mesangium with granular subendothelial deposits and moderate effacement of podocyte foot processes. G, Electron microscopy showing mesangial areas with a fibril deposition. GBM = glomerular basement membrane. Mayo Clinic Proceedings: Innovations, Quality & Outcomes 2018 2, 297-302DOI: (10.1016/j.mayocpiqo.2018.04.003) Copyright © 2018 Terms and Conditions

Figure 2 Change in eGFR (mL/min/1.73 m2), ACR (mg/mmol), and paraprotein (g/L) with time. Arrow indicate initiation of treatment with VCD and later with CTD. ACR = albumin to creatinine ratio; CTD = cyclophosphamide, thalidomide, and dexamethasone; eGFR = estimated glomerular filtration rate; VCD = velcade, cyclophospahamide, and dexamethasone. Mayo Clinic Proceedings: Innovations, Quality & Outcomes 2018 2, 297-302DOI: (10.1016/j.mayocpiqo.2018.04.003) Copyright © 2018 Terms and Conditions