Presumed Monozygotic Twin Kidney Transplantation with a Thin Basement Membrane Nephropathy Donor: A Case Report

Identical or Monozygotic twin kidney transplant usually possess an excellent immunological match and provide the opportunity to minimize or even avoid immunosuppression toxicity. However, there are concerns regarding disease recurrence among end stage kidney disease (ESKD) patients with an unknown etiology. Together with the risk of inherent, familial disease affecting donors and recipients alike, more invasive tests such as a pretransplant biopsy are being considered to ascertain renal prognosis. A 30-year-old female, known case of CKD Stage 5D from an unknown etiology, with secondary hyperparathyroidism and heart failure, presented at our OPD for kidney transplantation. Her donor is her identical twin who is asymptomatic and denies comorbidities. The recipient discloses a previous history of blood transfusion. Immunological workup revealed the following: matched blood type, zero HLA mismatch, negative T-cell tissue crossmatch but with a positive Class I HLA antigen screen. Antibody specificity revealed the presence of donor specific antibodies (DSA). After workup completion, the patient underwent a right kidney transplant with a preimplantation wedge biopsy on the donor kidney. Immediate graft function was noted post operatively. The wedge biopsy revealed a thinned glomerular basement membrane, consistent with Thin Basement Membrane Nephropathy (TBMN). The patient was started on immunosuppression and prophylaxis during the duration of the post operative period without any complications. Five months post-transplant, both the recipient and donor maintain an adequate renal function without any signs of allograft rejection. In this case report, we have demonstrated that TBMN may serve as a viable donor for a presumed monozygous twin kidney transplantation. When a live donor with TBMN is being considered, a thorough work-up and identification of high-risk features are essential to exclude other progressive renal diseases during the pretransplant evaluation.