An important finding of our study is the presence of monoclonal gammopathy and proliferative glomerulonephritis. Recently, Nasr et al. described a novel

form of proliferative Selleckchem SCH772984 glomerulonephritis associated with monoclonal IgG deposits (PGNMID) characterized by diffuse proliferative, membranoproliferative, or membranous features on light microscopy and glomerular monoclonal IgG deposits restricted to a single IgG subclass and a single light-chain isotype on IF microscopy.[3] On EM, granular, non-organized deposits were detected, typically in a sub-endothelial and mesangial distribution. Thirty per cent of patients have a detectable level of circulating monoclonal protein with the same heavy- and light-chain isotypes as those of the glomerular deposits. Over 40 additional patients buy RXDX-106 with PGNMID in the native kidney have been reported by

other groups.[4-9] The present case may be similar to those discussed in these studies, except for the presence of mesangial and segmental endocapillary proliferation secondary to monoclonal IgA2 λ light-chain deposition. Although the existence of underlying lymphoplasmacytic disorders remains to be determined by bone marrow biopsy, we believe that the capillary wall deposition of other monoclonal Igs, including monoclonal IgA, can result in a proliferative glomerulonephritis pattern of injury. Recurrent glomerular diseases usually develop early post transplantation, whereas de novo glomerular diseases usually develop several years after kidney transplantation. Furthermore, the possible development of recurrent or de novo PGNMID after kidney transplantation has been reported.[10-12] Whether the present case represents recurrent or de novo glomerulonephritis in terms of IgA2-λ monoclonality remains to be determined, and we lack the native kidney biopsy material to prove the similarity of the morphological features and the presence of

monoclonal deposits. However, because the patient had obvious IgA2 mesangial and glomerular capillary deposits 1 year post transplantation, it is likely that the clinical history was consistent with recurrent disease. The initial three allograft biopsies performed without immunostaining for anti-light chain antibodies showed recurrent IgAN. Because of the lack of proven effective therapeutic approaches for recurrent IgAN,[1, 13] we treated Thiamet G the patient with rituximab, which has been shown to be effective in treating patients with nephrotic syndrome.[14, 15] However, the treatment failed to improve renal function. A recent small trial conducted by Sugiura et al. in adults with IgAN found no benefit of rituximab for the reduction of proteinuria at 6 months, although the dose of steroids was reduced.[16] The optimum dose of rituximab is also unknown, although prescribing the minimal dose needed to achieve B-cell depletion may be as clinically effective and cost-effective as conventionally prescribed doses.