1. A 46 year old man with reduced gfr and nephrotic syndrome
Knut Aasarød
Dept. of Nephrology
Trondheim University Hospital

2. Previously mostly healthy man.
Slight depressive symptoms, a period of high alcohol consumption.
Both parents hypertensive
A history of edema in 1990, resolved
May 2007 at his GP: s-creatinine 111 µmol/l
No actions taken
Knut Aasarød

3. 2007 – 2008 generally reduced well-being
Shortnes of breath on climbing a few stairs
Frontal headache, dizziness
On admission Oct. 2008
BP 230/130 mmHg, HR 112 sr
Edema around both ankles
Ecco-cardiography: LVH, reduced speed of relaxation
Retinal us: hypertensive retinopathy grade 2
Knut Aasarød

4. BP Hgb Trc s-Creatinine s-albumin ANA/subgroups ANCA/aGBM C3 and C4
Oct 2008
Kidney biopsy
April 2009
April – Sept 2009
Nov 2009 BP
230/130
160/103
Cs+ cyclo phosphamide
128/90
Hgb
12,1 g/dl
11,6 g/dl
Trc
291
s-Creatinine
200 µmol/l
253µmol/l
255µmol/l
s-albumin
30 g/l
32 g/l 39
ANA/subgroups
Neg
ANCA/aGBM
C3 and C4 N
Hep B/C
HIV
Cryoglob.
s-κ/λ ratio
s-ELFO
Urin dipstick
Alb4+/blood 2+
U-alb/creat.
512 mg/mmol
386
mg/mmol
12,9 mg/mmol
Knut Aasarød

5. BP Hgb Trc s-Creatinine s-albumin Urin dipstick U-alb/creat. Aug. 2011
Sept. 2011
Oct 2012
Feb. 2015
Hemodialysis
From April 2015 BP
129/85
131/92
CyA + CS
Kidney biopsy.
144/98
Hgb
12,0 g/dl
11,6 g/dl
Trc
170
s-Creatinine
154 µmol/l
221µmol/l
401µmol/l
s-albumin
36 g/l
39 g/l
Urin dipstick
Alb2+/bl. 0
Alb2+/bl. 3+
Alb 5+/Bl 5+
U-alb/creat.
154 mg/mmol
279 mg/mmol
574 mg/mmol
About 2 years later, creatinine nadir in August 2011, but albuminuria has started to rise
Knut Aasarød

6. Received a LD transplant from a 25 year old daughter
7 th January 2016
Received a LD transplant from a 25 year old daughter
0 A / HLA / CMV CMV+
Prednisolon/tacrolimus/MMF
s-creatinine 120 µmol/l
6 weeks post TX: creatinine 150 µmol/ + albuminuria
TX biopsy
Knut Aasarød

7. Post transplant BP Hgb Trc s-Creatinine s-albumin ANA/subgroups
March. 2016
Nov. 2016
April 2017
Aug. 2017 BP
145/96
137/82
TX biopsy
123/80
Hgb
16,5 g/dl
16,2 g/dl
Trc
s-Creatinine
120 µmol/l
97 µmol/l
103 µmol/l
s-albumin
37 g/l
38 g/l
34 g/l
ANA/subgroups
Neg
C3 and C4 N
Hep B/C
HIV
Cryoglob.
s-κ/λ ratio
s-ELFO
Urin dipstick
Alb3+/bl. 5+
Alb 3+/Bl 5+
U-alb/creat.
104 mg/mmol
115 mg/mmol
228 mg/mmol
Knut Aasarød

8. Concerns regarding this patient
Was it an immune complex disease?
Use of living related donor?
What now?
Rituximab?
PE?
Cyclophosphamide?
Knut Aasarød

9. MPGN – recurrence after kidney transplantation
Independent variable
Hazard ratio (CI)
P-value
Age at transplantation
1.019 (0.937–1.018)
0.65
Gender (Male)
1.00 (0.118–8.420) 1
Race (Caucasian)
1.5 (0.120–18.411)
0.1
Allograft source (Living related)
10.19 (0.866–12.96)
0.045
Duration of dialysis
0.951 (0.775–1.167)
0.612
Preemptive transplantation
6.322 (1.455–12.411)
0.018
Previous failed transplantation
0.833 (0.098–7.026)
0.86
DGF (In deceased donor)
1.21 (0.158–9.508)
0.83
Development of rejection
3.148 (0.854–9.546)
0.25
Use of ACEi/ARB
1.312 (0.587–5.847)
0.658
Low complement level
5.522 (1.632–18.679)
0.006
Evidence of monoclonal gammopathy
5.606 (1.522–20.642)
0.010
Alasfar S et al. BMC Nephrology 2016
Knut Aasarød