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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 13  |  Issue : 1  |  Page : 54-55

Living kidney donor with monoclonal gammopathy of undetermined significance: Is it a contraindication for kidney donation?


Department of Nephrology, Sawai Man Singh Medical College, Jaipur, Rajasthan, India

Date of Web Publication29-Mar-2019

Correspondence Address:
Vinay Rathore
Department of Nephrology, Sawai Man Singh Medical College, Jaipur - 302 004, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_67_18

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  Abstract 


Kidney transplantation is the treatment of choice for patients suffering from end-stage renal disease. We report a case of living kidney transplantation in which the donor had monoclonal gammopathy of undetermined significance, a condition having possible implication for both donor and recipient. Both donor and recipient had an uneventful course in short-term follow-up of 1 year following kidney transplantation.

Keywords: End-stage renal disease, kidney transplantation, light chain, living donor, monoclonal gammopathy of undetermined significance


How to cite this article:
Rathore V, Beniwal P, Agarwal D, Malhotra V, Jhorawat R, Sharma S. Living kidney donor with monoclonal gammopathy of undetermined significance: Is it a contraindication for kidney donation?. Indian J Transplant 2019;13:54-5

How to cite this URL:
Rathore V, Beniwal P, Agarwal D, Malhotra V, Jhorawat R, Sharma S. Living kidney donor with monoclonal gammopathy of undetermined significance: Is it a contraindication for kidney donation?. Indian J Transplant [serial online] 2019 [cited 2019 Jul 21];13:54-5. Available from: http://www.ijtonline.in/text.asp?2019/13/1/54/255190




  Introduction Top


Kidney transplantation is the treatment of choice for end-stage renal disease (ESRD).[1] Transplantation offers superior survival and better quality of life and is cost-effective compared to maintenance dialysis.[1],[2] In developing countries like India where deceased donor program is still in infancy, living donor renal transplantation may be the only hope for patient suffering from ESRD, particularly those who do not have access to dialysis facility.

During evaluation of living donor, one may come across scenarios in which decision on accepting or rejecting a donor can be difficult. We came across a similar scenario, in which monoclonal gammopathy of undetermined significance (MGUS) was detected in a prospective renal donor. Most of the published clinical practice guidelines on evaluation of living kidney donor have not considered MGUS.[3],[4],[5]

After multidisciplinary evolution, including hematologist, oncologist, and nephrologist and explanation of risk of kidney transplantation to both donor and recipient, kidney transplantation was carried out.


  Case Report Top


A 23-year-old female was diagnosed with chronic kidney disease 5 years back. She progressed to ESRD and was started on renal replacement therapy with thrice weekly hemodialysis. She was referred to our institute with the prospect of renal transplantation. She also had hypertension, anemia, and hypothyroidism (controlled on thyroxin at a dose of 50 μg/day). She was evaluated and was found to have no contraindication for renal transplantation.

Her mother aged 50 years came forward as a prospective renal donor. She was ABO compliable to the patient. She had no contraindication to renal donation, except for persistent proteinuria (maximum of 280 mg/day) which was negative by urinary dipstick, suggesting a possibility of overflow proteinuria. Serum-free light chain (FLC) kappa and lambda were 54.6 mg/L and 17.4 mg/L, respectively, with FLC ratio of 3.14. She was further evaluated for the possibility of myeloma; however, her bone marrow aspiration revealed 5% plasma cells and she had no CRAB (increased Calcium level, Renal dysfunction, Anemia, and Bone lesions) features (hemoglobin – 13.1 g/dl, serum creatinine – 0.9 mg/dl, and serum calcium – 8.8 mg/dl). Skeletal survey did not reveal any osteolytic lesions and there was no expression of the monoclonal peak of the immunoglobulin H in the serum on immunofixation; hence, the diagnosis of light chain MGUS was made.

Donor and recipient were counseled regarding the diagnosis, risk of progression to multiple myelomas (MMs), and its possible implication on both donor and recipient by a multidisciplinary team consisting of nephrologists, hematologists, and oncologists. Following clearance from multidisciplinary team, the patient underwent renal transplantation in June 2017, with induction therapy consisting of basiliximab, mycophenolate mofetil, tacrolimus, and prednisolone. The posttransplant period was uneventful. The patient was discharged on maintenance immunosuppression of mycophenolate mofetil, tacrolimus, and prednisolone.

At 1 year of follow-up, the patient had a serum creatinine of 1.3 mg/dl. Her serum protein electrophoresis and serum immunofixation revealed no monoclonal protein. The donor was also asymptomatic and had normal renal function.


  Discussion Top


MGUS is a common asymptomatic premalignant stage defined by the presence of serum monoclonal protein, but not fulfilling the criteria for other malignant diseases such as MM. The diagnostic criteria for MM and MGUS have been recently laid down by the International Myeloma Working Group.[6] It is a common condition with the prevalence of 3%–4% of the population over the age of 50 years.[6] With such a high prevalence, it is quite possible to encounter MGUS while evaluating a prospective renal donor.

Although benign, MGUS carries the risk of malignant transformation. The risk of malignant transformation has been estimated to be 1% per year.[7] MGUS in a prospective renal donor has potential implication for both donor and recipient. For the donor, potential progression of MGUS may lead to more severe renal disease in single kidney. For the recipient, there is potential for the transmission of monoclonal cells which may progress to MM, particularly in the setting of immunosuppression.

We reviewed various published living kidney donor guidelines.[3],[4],[5] Most of the guidelines including recently published KDIGO guidelines clearly contradict active malignancy including monoclonal gammopathy as renal donor; however, MGUS has not been reviewed. A recent case report had described two cases of living donor who had MGUS.[8] Neither recipient nor donor had developed complication during the follow-up of 42 and 36 months, respectively. Similarly, Cheungpasitporn et al. have not found progression of MGUS to MM in four living kidney donors with MGUS after a mean follow-up of 5 years.[9]

At 1 year of follow-up, both donor and recipient had uneventful course in the index case, reassuring us about successful outcome at least in short-term. Clearly, more data with long-term outcomes are needed to develop protocols for such scenario.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LY, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725-30.  Back to cited text no. 1
    
2.
Rosselli D, Rueda JD, Diaz CE. Cost-effectiveness of kidney transplantation compared with chronic dialysis in end-stage renal disease. Saudi J Kidney Dis Transpl 2015;26:733-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Lentine KL, Kasiske BL, Levey AS, Adams PL, Alberú J, Bakr MA, et al. KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Transplantation 2017;101:S1-109.  Back to cited text no. 3
    
4.
Delmonico F, Council of the Transplantation Society. A report of the Amsterdam forum on the care of the live kidney donor: Data and medical guidelines. Transplantation 2005;79:S53-66.  Back to cited text no. 4
    
5.
OPTN (Organ Procurement and Transplantation Network)/UNOS (United Network for Organ Sharing). OPTN Policies, Policy 14: Living Donation. Available from: http://www.optn.transplant.hrsa.gov/governance/policies/. [Last accessed on 2017 Jun 28].  Back to cited text no. 5
    
6.
Rajkumar SV, Dimopoulos MA, Palumbo A, Blade J, Merlini G, Mateos MV, et al. International myeloma working group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol 2014;15:e538-48.  Back to cited text no. 6
    
7.
Kyle RA, Durie BG, Rajkumar SV, Landgren O, Blade J, Merlini G, et al. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering (asymptomatic) multiple myeloma: IMWG consensus perspectives risk factors for progression and guidelines for monitoring and management. Leukemia 2010;24:1121-7.  Back to cited text no. 7
    
8.
Serra N, Revuelta I, Bladé J, Oppenheimer F, Campistol JM. Monoclonal gammopathy of undetermined significance: A contraindication for living kidney donation? NDT Plus 2011;4:256-7.  Back to cited text no. 8
    
9.
Cheungpasitporn W, Thongprayoon C, Erickson SB. Outcomes of living kidney donors with monoclonal gammopathy of undetermined significance. Ren Fail 2015;37:1070-1.  Back to cited text no. 9
    




 

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