nephrology

1. RECURRENT GLOMERULONEPHRITIS AFTER
KIDNEY TRANSPLANTATION :RISK FACTORS
AND ALLOGRAFT OUTCOMES
(KIDNEY INTERNATIONAL 2017)
SCIENTHIA SANJEEVANI
MODERATOR-DR SAHIL BAGAI
12-12-2018

2. INTRODUCTION
• Australia and New Zealand Dialysis and Transplant (ANZDATA)
Registry showed that 46 % of transplant recipients have
glomerulonephritis as etiology of ESRD
• reported rates of recurrence of GN after transplant varying widely,
from 2.6% to 50% in previous studies
• reported allograft loss rates attributed to disease recurrence vary
between 7% and 55%. (ANZDATA-8.4 %)
• Recurrent GN is the fourth most common cause of allograft loss
after acute rejection, chronic allograft nephropathy, and death
with a functioning allograft.

3. EPIDEMIOLOGY-AN OVERVIEW

4. ANZDATA STUDY

5. BASELINE CHARACTERISTICS

6. BASELINE CHARACTERISTICS (CONTD.)

7. TO SUMMARIZE
• YOUNGER
• MALE
• WHITE
• MOST COMMON IgA
• MINIMAL HLA MISMATCHES
• IMMUNOSUPPRESION AT BASELINE –STEROID FREE REGIMEN IN CASE
OF IgA
• DONOR CHARACERISTICS- YOUNG, LIVING

8. RECURRENCE RATE
5YRS 10 YRS 15 YRS
IgA 5.1% 10.1 % 15%
MPGN 11.8% 15.6 % 18.9%
FSGS 7.3% 9% 11%
MGN 10% 16% 18%

9. RISK FACTORS FOR RECURRENCE

10. DISEASE RECURRENCE AND GRAFT LOSS

11. Kaplan–Meier estimates of overall and death-censored allograft loss in those with and without
recurrent glomerulonephritis (BLUE- NO RECURRENCE , RED –RECURRENCE )

12. Causes of allograft loss in recipients with recurrent
glomerulonephritis

13. Allograft survival after recurrence, stratified
by GN type
MPGN FSGS IgA MGN
5 YR
SURVIVAL
RATE
30 % 57% 58% 59%

14. RESULT
• Overall incidence of disease recurrence after transplantation for
the 4 most common GN subtypes was approximately 10%.
• Of these, 45% lost their allografts within 5 years.
• Compared with recipients with no GN recurrence, the risks of
overall and death-censored allograft failure were double in those
with recurrence.
• MPGN was associated with the worst graft survival compared with
others

15. DISCUSSION
CLINICAL PRESENTATIONS
• IgA nephropathy-
 recurrent disease generally slow to cause renal impairement and
graft loss
Inconspicuous, with asymptomatic haematuria +/-renal
dysfunction  delayed histological confirmation
Common with living donors
maintenance corticosteroids reduced the likelihood of reported
disease recurrence

16. • FSGS
Risk factors include: young age of the recipient, duration of native
disease from onset to development of end-stage renal failure,
mesangial proliferative pathology,higher in related donor grafts.
may be caused by a circulating plasma factor, probaby glomerular
podocyte antibodies
• MPGN and FSGS- present with significant proteinuria and renal
dysfunction , prompting early diagnosis

17. Strengths of study
• largest and most clinically diverse group of kidney transplant
recipients
• By focusing on the 4 most common GN subtypes, complete biopsy
information was available for all the transplant recipients

18. Limitations
• Inconsistent primary disease coding may occur(nonbiopsied cases
of “presumed,” “advanced,” or “other” primary GN were not
included)
• did not capture the duration between time of original GN
diagnosis and time of requiring renal replacement therapy.
• misclassification or incorrect coding of recurrence events at the
stage of data entry

21. Other studies
• Kidney Transplantation Outcomes across GN Subtypes in the
United States
- IgA nephropathy (IgAN) had the lowest mortality rates and patients
with IgAN or vasculitis had the lowest allograft failure rates
• Long-term Kidney Transplant Outcomes in Primary
Glomerulonephritis: Analysis From the ERA-EDTA Registry
-favorable long-term kidney graft survival in all primary
glomerulonephritides (all >55% in 15 yr duration, although lower
than graft survival in ADPKD

22. Conclusion
• GN recurrence is an unavoidable, unpredictable, and feared outcome
after transplantation.
• Regular surveillance of these at-risk transplant recipients using protocol
biopsies and routine clinical monitoring may detect recurrence early and
treat in time to prevent further disease progression.
• The success of screening measures depends on the availability of
effective treatments( rituximab is a potential treatment for some types
of recurrent GN)
• Communication and counselling about the risk of disease recurrence to
patients and potential live donors is an important aspect of patient
education before transplantation