Numata Akihiko, Morishita Yoshiyuki, Mori Masaki, Saito Osamu, Takemoto Fumi, Ando Yasuhiro, Muto Shigeaki, Yumura Wako, Kusano Eiji
Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan.
Exp Clin Transplant. 2013 Feb;11(1):75-8. doi: 10.6002/ect.2012.0078. Epub 2012 Jul 18.
We report membranous nephropathy in a 61-year-old man after allogeneic hematopoietic stem cell transplant without chronic graft-versus-host disease. A diagnosis of acute myeloid leukemia was made, and the patient received hematopoietic stem cell transplants, twice, from different donors. The first donor was his brother and the second donor was an unrelated man. Human leukocyte antigens between donors and recipient were fully matched. His clinical course was stable without acute or chronic graft-versus-host disease or relapse of acute myeloid leukemia with tacrolimus after the second hematopoietic stem cell transplant. Six months after the second hematopoietic stem cell transplant, tacrolimus was decreased gradually and discontinued because of tacrolimus-induced liver dysfunction. Three months after discontinuing the tacrolimus, the patient developed edema in his leg. The results of a blood analysis showed that plasma albumin level was 21 g/L and plasma total cholesterol level was 11.5 mmol/L, while results from a urinalysis showed proteinuria of 5.6 g/d without hematuria. No abnormalities in the skin, mucosal tissues, and other organs suggestive of chronic graft-versus-host disease were seen. A renal biopsy was done to investigate the cause, which revealed renal disease. Electron microscopic analysis showed dense deposits in the subepithelial region in all glomeruli. Immunofluorescence analysis showed the deposition of IgG4 and C3c in the subepithelial space of all glomeruli. Membranous nephropathy was diagnosed. He then was administered prednisolone at a dosage of 45 mg/d (0.7 mg/kg/d). After prednisolone treatment, urine protein and hypoalbuminemia were markedly improved, and his leg edema disappeared. These results suggest that this membranous nephropathy may have been de novo membranous nephropathy after hematopoietic stem cell transplant because it developed after hematopoietic stem cell transplants without chronic graft-versus-host disease.
我们报告了一例61岁男性在异基因造血干细胞移植后发生的膜性肾病，该患者无慢性移植物抗宿主病。患者被诊断为急性髓系白血病，并接受了两次来自不同供者的造血干细胞移植。第一位供者是他的兄弟，第二位供者是一位无关男性。供者与受者之间的人类白细胞抗原完全匹配。第二次造血干细胞移植后，他的临床过程稳定，无急性或慢性移植物抗宿主病，也无急性髓系白血病复发，使用他克莫司进行治疗。第二次造血干细胞移植6个月后，由于他克莫司引起的肝功能障碍，他克莫司逐渐减量并停用。停用他克莫司3个月后，患者出现腿部水肿。血液分析结果显示血浆白蛋白水平为21 g/L，血浆总胆固醇水平为11.5 mmol/L，而尿液分析结果显示蛋白尿为5.6 g/d，无血尿。未发现皮肤、黏膜组织及其他器官有提示慢性移植物抗宿主病的异常。进行了肾活检以探究病因，结果显示为肾病。电子显微镜分析显示所有肾小球的上皮下区域有致密沉积物。免疫荧光分析显示所有肾小球的上皮下间隙有IgG4和C3c沉积。诊断为膜性肾病。随后给予患者泼尼松龙，剂量为45 mg/d（0.7 mg/kg/d）。泼尼松龙治疗后，尿蛋白和低蛋白血症明显改善，腿部水肿消失。这些结果表明，这种膜性肾病可能是造血干细胞移植后新发的膜性肾病，因为它发生在无慢性移植物抗宿主病的造血干细胞移植之后。
