Plasma exchange-sensitive syncytial glomerulopathy in a kidney transplant patient

Microvascular inflammation (MVI), defined as the presence of glomerulitis and/or peritubular capillaritis, is the key histological lesion of anti-HLA donor-specific antibodies (DSA)-related antibody mediated rejection, but recently other possible mechanisms of MVI have emerged. However, except for peritubular capillary C4d deposition that is more frequently observed in the presence of anti-HLA-DSA, histological features are similar regardless of MVI origin. Therefore, accurately describing patterns of MVI may help differentiate etiologies and drive therapeutic choices. We describe the case of a kidney transplant recipient (primary nephropathy: autosomal dominant polycystic kidney disease) who underwent kidney biopsy for worsening renal function and new onset hypertension. Histologic findings showed severe microvascular inflammation with intense glomerulitis and presence of intracapillary multinucleated cells, positive on immunostaining for endothelial marker ETS-related gene (ERG). Focal intense peritubular capillaritis and early glomerular basement membrane reduplication, C4d negative, were observed, consistent with early chronic active ABMR. HLA-DSA were absent, but high level of anti-angiotensin II type-1 receptor (AT1R) antibodies (Ab) were detected (78 U/L, normal levels < 10 U/L). Two subsequent biopsies showed intense microvascular inflammation with diffuse peritubular capillaritis, and multinucleated, ERG-positive, endothelial cells were still seen in glomerular capillary loops. The patient was started on angiotensin receptor blockers (ARBs) and plasma exchange (PEX) sessions obtaining normalization of blood pressure and AT1R Ab and proteinuria reduction, but, after subsequent liver transplant, rituximab therapy failed to maintain remission and the patient remained PEX-dependent.