C3 glomerulopathy post kidney transplantation: A single center experience

Table 1 Clinical findings and native biopsy findings

ID	Age	Sex	Native kidney diagnosis	Native kidney biopsy findings on re-examination	Transplant year	Allograft type	Induction	Biopsy Indication	Maintenance immunotherapy at bx	Serum creatinine (mg/dL) at bx	Proteinuria at bx	Time to diagnosis of C3G post kidney transplant (months)	Post-transplant C3G treatment	Graft/Patient survival from time of transplant (months)	Clinical follow up time from transplant (months)	Renal function at last follow-up (mg/dL)
C3GN-1	40	F	MPGN type 1	LM: MPGN; IF: C3 (4+); EM: Mesangial/subepithelial (some large)/subendothelial deposits	2018	DDRT	ATG	Hematuria	Pred/fk/mmf	1.44, eGFR 47	UPC 0.2	10	Duodenal PTLD	60	64	ESRD
DDD-1	70	M	MPGN type 1	Unknown	2015	DDRT	ATG	AKI, hematuria	Pred/fk	2.9, eGFR 26	UPC 0.4	7	Crypto meningitis	18	18	Cr 0.93 - Death
DDD-2	27	M	DDD	Unknown	2005 (first), 2010 (second)	LURT	Simulect	Protocol	Pred/fk/mmf	NA	UPC 0.8	3 (first); 31 (second)	None	11	109	Retransplant Cr 1.4
DDD-3	37	M	DDD	Unknown	2007	DDRT	ATG	Hematuria	Pred/fk/mmf	2.5, eGFR	UPC 0.365	23	None	56	148	ESRD
DDD-4	16	M	DDD	Unknown	1991 (first), 1995 (second)	LRRT	None	Proteinuria, graft dysfunction	Pred/imuran	1.3	2+	25	None	47	53	ESRD
DDD-5	11	M	DDD	LM: MPGN with approximately 53% active crescents; IF: C3 (4+); EM: Intramembranous, mesangial deposits	1992 (first), 3/2002 (second)	DDRT	Simulect	Hematuria, proteinuria	Pred/cyclo/imuran	NA	3+ blood, 3+ protein	2 (first), 4 (fecond)	None	19	95	ESRD
DDD-6	11	F	DDD	LM: MPGN; no IF tissue; EM: Intramembranous deposits	2008 (first), 2023 (second)	DDRT	Simulect	Protocol	Pred/fk/mmf	0.6	NA	6	None	11	188	Retransplant Cr 0.85
C3GN-2	44	M	MPGN	Unknown	2012	LURT	Campth	Protocol	Fk/mmf	1.3	NA	24	Steroids × 2 weeks	140	140	2.3
C3GN-3	21	M	C3GN	LM: MPGN; IF: C3 (4+); EM: Mesangial, subendothelial, intramembranous, hump-like deposits	2019	LURT	ATG	Proteinuria	Pred/fk/mmf	1.38	UPC 0.1	4	Eculizumab	47	47	1.34
C3GN-4	19	F	C3GN	LM: MPGN; IF C3(2-3+); IgM (1-2+); EM: Mesangial, intramembranous, subendothelial, subepithelial, hump like deposits	2017	DDRT	ATG	AKI, proteinuria	Pred/fk/mmf	1.15	UPC 1.6	5	Eculizumab	73	73	3.8
C3GN-5	46	F	C3GN	LM: MPGN, IF: C3(4+) EM: Subendothelial and mesangial deposits	2014	LURT	Simulect	Proteinuria, AKI	Pred/fk/mmf	2.8	3+	2	Pheresis+ eculiuzmab × 1 year (6 months after diagnosis)	41	82	ESRD
DDD-7	15	M	MPGN type 1	Unknown	2004	LRRT	Simulect	Protocol	Pred/fk/mmf	1.2	UPC 0.1	60	Eculizumab in 2023 with graft dysfunction and proteinuria	230	230	1.93
DDD-8	22	F	DDD	LM: MPGN; IF: C3 (4+), IgG (trace), IgM (1+), and kappa and lambda light chains (both 1+); EM: Mesangial, intramembranous, and hump-like deposits	2016	LRRT	Simulect	Proteinuria	Pred/fk/mmf	0.7	3+ hematuria, UPC 0.1	2	Eculizumab	89	91	1.25
C3GN-6	21	F	MPGN type 1	LM: MPGN; IF: C3 (4+), IgG (3-4+), IgA (1+), IgM (2+), C1q (2+), kappa light chain (1+), and lambda light chain (2+); EM: Subendothelial and mesangial deposits	2012	DDRT	ATG	AKI, hematuria, proteinuria	Pred/fk/mmf	2.7	4.2 g	11	Pheresis + eculizumab (start 1 year after for only 3 months)	48	77	ESRD
C3GN-7	17	F	Crescentic glomerulonephritis consistent with granulomatosis with polyangiitis; PR3+/ C-ANCA	Unknown	2009	LURT	Daclizumab	AKI with proteinuria during PTLD	Pred/fk	2.2	1.5 g	153	Treatment steroids/rituximab for PTLD dx 14 months prior	159	159	AKI-CRRT - Death

C3GN: C3 Glomerulonephritis; MPGN: Membranoproliferative glomerulonephritis; LM: Light microscopy; IF: Immunofluorescence Microscopy; EM: Electron Microscopy; eGFR: Estimated glomerular filtration rate; NA: Not available; DDRT: Deceased donor renal transplant; ATG: Anti-thymocyte globulin; UPC: Urine protein to creatinine ration; PTLD: Post-transplant lymphoproliferative disorder; ESRD: End-stage renal disease; DDD: Dense deposit disease; AKI: Acute kidney injury; LURT: Living unrelated renal transplant; LRRT: Living related renal transplant; ANCA: Anti-neutrophil cytoplasmic antibodies; CRRT: Continuous renal replacement therapy.

Table 2 Kidney biopsy findings, n (%)

Parameter	Index biopsy	Any biopsy
Light microscopy pattern
No hypercellularity	3 (19)	3 (19)
Mesangial proliferative GN only	2 (13)	3 (19)
Endocapillary proliferative GN only	5 (31)	5 (31)
Mesangial and endocapillary proliferative GN	4 (25)	4 (25)
Membranoproliferative GN	5 (31)	10 (63)
Exudative features	4 (25)	4 (25)
Active crescents	3 (19)	5 (31)
Segmental glomerular scars	5 (31)	9 (56)
Concurrent biopsy findings
Cellular rejection	6 (38)	8 (50)
Antibody mediated rejection	2 (13)	4 (25)
Thrombotic microangiopathy	1 (6)	3 (19)
Acute/chronic CNI toxicity	2 (13)	5 (31)
Arterio/arteriolosclerosis	4 (25)	4 (25)
BK virus nephropathy	1 (6)	1 (6)
Acute tubular injury	2 (13)	4 (25)
None	3 (19)	3 (19)
Immunofluorescence findings
C3 only	7 (44)	9 (56)
C3 dominant	9 (56)	9 (56)
Non-C3 dominant GN	1 (6)	1 (6)
Electron microscopy findings
Mesangial deposits	12 (75)	13 (81)
Subendothelial deposits	7 (44)	9 (56)
Subepithelial	7 (44)	10 (63)
Intra-membranous deposits	12 (75)	13 (81)
Tubular basement membrane deposits	7 (44)	7 (44)
Subepithelial “hump-like” deposits	5 (31)	7 (44)

C3GN = 7, DDD = 8. GN: Glomerulonephritis; DDD: Dense deposit disease; CNI: Calcineurin inhibitor.