A de novo monoclonal immunoglobulin deposition disease in a kidney transplant recipient: a case report

Abstract

IntroductionMyeloma following kidney transplantation is a rare entity. It can be divided into two groups: relapse of a previous myeloma and de novo myeloma. Some of these myelomas can be complicated by a monoclonal immunoglobulin deposition disease, which is even less common. Less than ten cases of monoclonal immunoglobulin deposition disease after renal graft have been reported in the literature. The treatment of these patients is not well codified.Case presentationWe report the case of a 43-year-old white European man who received a renal transplant for a nephropathy of unknown etiology and developed a nephrotic syndrome with kidney failure at 2-years follow-up. We diagnosed a de novo monoclonal immunoglobulin deposition disease associated with a kappa light chain multiple myeloma, which is a very uncommon presentation for this disease. Three risk factors were identified in this patient: Epstein–Barr virus reactivation with cytomegalovirus co-infection; intensified immunosuppressive therapy during two previous rejection episodes; and human leukocyte antigen-B mismatches. Chemotherapy treatment and decrease in the immunosuppressive therapy were followed by remission and slight improvement of renal function. A relapse occurred 8 months later and his renal function worsened rapidly requiring hemodialysis. He died from septic shock 4 years after the diagnosis of monoclonal immunoglobulin deposition disease.ConclusionsThis rare case of post-transplant lymphoproliferative disorder with an uncommon presentation illustrates the fact that treatment in such a situation is very difficult to manage because of a small number of patients reported and a lack of information on this disease. There are no guidelines, especially concerning the immunosuppressive therapy management.

Three cases of de novo multiple myeloma after kidney transplantation

“…Resulta complicado diferenciar el mieloma múlti-ple de nuevo diagnóstico de una recaída después del trasplante, porque muchas veces se trata de formas subclínicas de la enfermedad presentes antes del trasplante que no se detectan con los exámenes del protocolo (9). Además, en los pacientes con enfermedad renal crónica terminal de etiología idiopática diagnosticada antes del trasplante (30,8 % de los casos aquí presentados), no se hace biopsia renal porque no aporta información útil por tratarse de riñones con fibrosis y, en cambio, sí implica un mayor riesgo de complicaciones.…”

“…En dichos casos, el diagnóstico fue tardío y se requirieron dos biopsias del injerto, la primera de las cuales evidenció cambios intersticiales inusuales entre los túbulos, pero, posteriormente, los hallazgos típicos permitieron el diagnóstico definitivo sin que se registraran valores anormales en los estudios hematoló-gicos previos al trasplante (4)(5)(6)(7)(8)(9)(10)(11). La mayoría de los pacientes fueron tratados con esteroides, melfalán y talidomida; en dos casos se administró bortezomib, pero solo en uno de ellos se pudo recuperar la función renal; en los demás hubo una recuperación de los valores hematológicos, pero también, se requirió nefrectomía del injerto o terapia de reemplazo renal.…”