Moroni et al.[2] reported that death-censored graft survival at 15 years was approximately 10% lower in IgAN patients than in controls, suggesting that the culprit is IgAN recurrence. In fact, IgAN is one of the most common recurrent glomerulonephritis. The majority learn more of recurrent IgAN is not clinical but pathological. Factors deciding the activity of recurrent IgAN remain unclear. It is unpredictable when IgAN recurs

and why these recurrences occur immediately after transplantation. We report a case of active IgAN that recurred 19 days after transplantation. A 23-year-old man with ESRD underwent living-related ABO-identical pre-emptive kidney transplantation (PEKT) from his 57-year-old mother. At the age of 18, his urinalysis was normal. However, at the age of 19, 3+ proteinuria and 2+ occult blood were detected by annual physical examination. The abnormality on his urinalysis was diagnosed as IgAN by renal

biopsy, which showed mild to moderate mesangial hypercellularity, with fibrocellular crescent in 1 of 10 glomeruli (Fig. 1a). Subsequently, tonsillectomy was performed and steroid pulse therapy was initiated. However, unfortunately, nephrotic-range proteinuria still developed. The patient then progressed to ESRD regardless of the treatment with steroid pulse therapy, cyclosporine (CyA), prednisolone, a renin–angiotensin system inhibitor, an antiplatelet agent, and anticoagulation therapy. He was referred to our hospital to undergo PEKT from his mother. Laboratory data revealed ESRD with a serum creatinine concentration histone deacetylase activity of 8.53 mg/dL, haemoglobin of 8.8 g/dL and serum albumin of 3.54 g/dL. Urinalysis showed 3+ proteinuria and microscopic haematuria. PEKT was performed when the patient was 23

years old. Initial immunosuppressive therapy consisted of prednisolone, mycophenolate mofetil, CyA and basiliximab, and the transplantation procedure was successful. Allograft biopsy performed 1 h after transplantation revealed normal glomeruli and an immunofluorescence study showed negativity for IgA and C3. The second biopsy was performed 19 days after transplantation to elucidate the cause of the increasing proteinuria (1.1 g/day) and serum creatinine (1.80 mg/dL). This biopsy showed segmental tuft necrosis with fibrin (Fig. 2a), and an immunofluorescence during study showed strong positivity for IgA and C3 (Fig. 2b). Neither acute rejection nor CyA nephrotoxicity was observed. These pathological findings and negative results for MPO-ANCA and PR3-ANCA completed the diagnosis of recurrent IgAN. The patient received steroid pulse therapy, double filtration plasmapheresis (DFPP), and anticoagulation therapy with warfarin. However, he developed nephrotic-range proteinuria and the serum creatinine concentration increased gradually. A cytomegalovirus infection made it inevitable to reduce the immunosuppressive agents.