Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Jan 18, 2022; 12(1): 15-20
Published online Jan 18, 2022. doi: 10.5500/wjt.v12.i1.15
Is de novo membranous nephropathy suggestive of alloimmunity in renal transplantation? A case report
Prakash I Darji, Himanshu A Patel, Bhavya P Darji, Ajay Sharma, Ahmed Halawa
Prakash I Darji, Himanshu A Patel, Department of Nephrology and Renal Transplantation, Zydus Hospitals, Ahmedabad 380059, Gujarat, India
Bhavya P Darji, Internship, Department of Medicine, GCS Medical College, Hospital and Research Centre, Ahmedabad 380025, Gujarat, India
Ajay Sharma, Ahmed Halawa, Faculty of Health and Life Science, Institute of Learning and Teaching, University of Liverpool, Liverpool L69 3BX, United Kingdom
Ajay Sharma, Consultant Transplant Surgeon, Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
Ahmed Halawa, Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom
Author contributions: Darji P conceptualized the study; Patel H contributed to writing the paper; Darji B contributed to writing and revising the paper; Sharma A and Halawa A contributed intellectual discussion and expertise to the study; and all authors reviewed and approved the final manuscript.
Informed consent statement: Written consent was obtained from the patient in their native language.
Conflict-of-interest statement: The authors declare no conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Ahmed Halawa, FRCS (Gen Surg), MD, MSc, Surgeon, Department of Transplantation, Sheffield Teaching Hospitals, Glossop Rd, Sheffield S10 2JF, United Kingdom.
Received: July 26, 2021
Peer-review started: July 26, 2021
First decision: October 27, 2021
Revised: December 8, 2021
Accepted: January 6, 2022
Article in press: January 6, 2021
Published online: January 18, 2022

Post-transplant nephrotic syndrome (PTNS) in a renal allograft carries a 48% to 77% risk of graft failure at 5 years if proteinuria persists. PTNS can be due to either recurrence of native renal disease or de novo glomerular disease. Its prognosis depends upon the underlying pathophysiology. We describe a case of post-transplant membranous nephropathy (MN) that developed 3 mo after kidney transplant. The patient was properly evaluated for pathophysiology, which helped in the management of the case.


This 22-year-old patient had chronic pyelonephritis. He received a living donor kidney, and human leukocyte antigen-DR (HLA-DR) mismatching was zero. PTNS was discovered at the follow-up visit 3 mo after the transplant. Graft histopathology was suggestive of MN. In the past antibody-mediated rejection (ABMR) might have been misinterpreted as de novo MN due to the lack of technologies available to make an accurate diagnosis. Some researchers have observed that HLA-DR is present on podocytes causing an anti-DR antibody deposition and development of de novo MN. They also reported poor prognosis in their series. Here, we excluded the secondary causes of MN. Immunohistochemistry was suggestive of IgG1 deposits that favoured the diagnosis of de novo MN. The patient responded well to an increase in the dose of tacrolimus and angiotensin converting enzyme inhibitor.


Exposure of hidden antigens on the podocytes in allografts may have led to subepithelial antibody deposition causing de novo MN.

Keywords: Post-transplant nephrotic syndrome, Recurrent membranous nephropathy, Secondary membranous nephropathy, Alloimmunity, Cryptic antigens, Case report

Core Tip: This is a case presentation of a patient who developed post-transplant nephrotic syndrome 3 mo after transplantation and was diagnosed with de novo membranous nephropathy (MN). He had received a well-matched living donor kidney. According to the literature, the most common causes of de novo MN include secondary causes and antibody mediated injury, which we ruled out. This patient was treated with increased dosage of tacrolimus and an angiotensin converting enzyme inhibitor, which resulted in a good recovery. We favoured a new concept of pathogenesis of de novo MN, which requires the identification of the causative antigens.