Donor-derived membranous nephropathy in the allograft kidney: A rare but probably underestimated complication

Transmitted donor-derived glomerular diseases in the allograft kidney are rare, especially when encountered in an allograft from a living donor. To date, only individual reports of donor-derived membranous nephropathy have been described. In this report, we present a case of membranous nephropathy discovered in a post-reperfusion biopsy of a living-donor allograft. A follow-up biopsy three weeks later demonstrated persistent deposits. Thirteen months post-transplantation, the recipient showed mildly worsening proteinuria but stable kidney function. To further our understanding of this exceedingly rare complication, we share our experience with seven additional in-house cases together with six cases described in the literature to date. A minority of the donors were living. Most donors did not exhibit significant proteinuria illustrating how pre-donation screening could potentially miss donor-derived membranous nephropathy. Reactivity for PLA2R and THSD7A were negative in all stained cases. On follow-up, recipients variably exhibited slow resolution of the immune deposits, variable degrees of proteinuria (mainly subnephrotic), and no significant impairment of kidney function. Donor-derived membranous nephropathy is rare, PLA2R-negative, and can still be encountered in living donors despite rigorous screening. This report provides a brief examination of the pathology, clinical, and laboratory features of such patients involved.