Recurrent Glomerulonephritis in the Renal Allograft: An Update of Selected Areas

Abstract

Glomerular diseases, including diabetes and various forms of glomerulonephritis, account for more than 70% of patients undergoing renal transplantation. Among these patients, more than 40% develop significant proteinuria, and around 15% develop persistent nephrotic syndrome. The most common cause of posttransplantation proteinuria is chronic allograft nephropathy (60%), followed by recurrent (15%) and de novo (10%) glomerulonephritis. Persistent proteinuria is associated with a significantly reduced rate of graft survival but often can be controlled with non–disease-specific therapy including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers with favorable effects on long-term prognosis.

Recurrent or de novo glomerulonephritis occurs in 6%-20% of patients overall and is more common in patients transplanted with glomerulonephritic organs. Glomerulonephritis in the allograft is also associated with a reduction in long-term (5-year) graft survival (40% vs 70%). The most common diseases associated with allograft glomerulonephritis and their recurrence rates in transplantation patients are idiopathic focal glomerular sclerosis (20%-30%), IgA nephropathy (25%), membranoproliferative glomerulonephritis (type 1, 25%; type 2, 80%), membranous nephropathy (30%), and hemolytic-uremic syndrome (classic, 10%; atypical, 40%; familial, 60%).

This article reviews new developments in the understanding of 3 of these diseases—focal glomerular sclerosis, membranous nephropathy, and hemolytic-uremic syndrome—as they relate to the incidence of recurrence, the effects of recurrence on graft survival, risk factors for recurrence, and management issues for nephrologists caring for patients with renal allografts. Proper donor selection, early diagnosis in high-risk patients, and appropriate management can prolong graft survival and improve long-term outcomes.