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A primer on recurrent and de novo glomerulonephritis in renal allografts

Nature Clinical Practice Nephrology volume 4, pages 446–457 (2008)Cite this article

Abstract

Accumulating evidence indicates that recurrent glomerulonephritis is the third most important cause of renal allograft loss at 10 years after transplantation. The proteinuria and elevated serum creatinine levels that result from recurrent glomerulonephritis are associated with cardiovascular morbidity and mortality. The exact prevalence of either recurrent or de novo post-transplantation glomerulonephritis is unknown because a considerable number of patients never undergo allograft biopsy, meaning that glomerulonephritis remains undiagnosed and a diagnosis of 'chronic rejection/chronic allograft nephropathy' is sometimes presumed. The lack of consensus regarding evaluation of kidney transplant recipients who exhibit slow deterioration of graft function is a major reason for underdiagnosis. All forms of glomerular disease can recur after transplantation, but the likelihood of recurrence differs according to type. Focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, IgA nephropathy and idiopathic diarrhea-negative hemolytic uremic syndrome often recur. Membranous nephropathy, focal segmental glomerulosclerosis, anti-glomerular basement membrane nephritis associated with Alport syndrome, and drug-induced thrombotic microangiopathy are the most common forms of de novo glomerulonephritis. This Review discusses the prevalence, risk factors, pathogenesis, clinicopathological features, and effects on graft outcome of recurrent and de novo glomerulonephritis in renal allografts. Treatment options are briefly outlined.

Key Points

  • Approximately 40% of kidney transplant recipients develop clinically relevant proteinuria; the most common cause is 'chronic rejection/chronic allograft nephropathy', with post-transplantation glomerulonephritis and calcineurin-inhibitor toxicity being the second most common causes

  • Glomerulonephritis is considered recurrent when the form that affected the native kidney recurs in the transplanted kidney; de novo (new-onset) glomerulonephritis is that which occurs in a transplant recipient whose original kidney disease was either not glomerular or was of a different pathological type

  • Recurrent and de novo post-transplantation glomerulonephritis have the same pathological features as disease that occurs in the native kidney but frequently coexist with glomerular manifestations of acute or chronic rejection

  • The prevalence of post-transplantation glomerulonephritis is not precisely known, mainly because of incomplete examination of graft biopsy samples and the lack of consensus regarding investigation of late allograft dysfunction

  • Focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, IgA nephropathy and idiopathic diarrhea-negative hemolytic uremic syndrome recur frequently after transplantation; membranous nephropathy, focal segmental glomerulosclerosis, anti-glomerular basement membrane nephritis in patients with Alport syndrome, and drug-induced thrombotic microangiopathy are the most common de novo diseases

  • Differential diagnoses and risk factors for recurrence of glomerulonephritis after transplantation need to be better defined in order to enable prompt diagnosis and treatment; multicenter studies on the optimum treatment strategies are also needed

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Figure 1: Recurrent post-transplantation focal segmental glomerulosclerosis, cellular variant (semithin plastic section, methylene blue staining, original magnification ×100).
Figure 2: De novo post-transplantation membranous nephropathy (stage III) and transplant glomerulopathy.
Figure 3: Protocol biopsy sample obtained 3 months after transplantation, showing recurrent IgA nephropathy.
Figure 4: Biopsy sample obtained 13 weeks after transplantation, showing thrombotic microangiopathy of obscure origin.

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  1. Department of Pathology, University of Szeged, Allomas utca 2, Szeged H-6720, Hungary ivanyi@patho.szote.u-szeged.hu

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  1. B Ivanyi is Professor of Pathology in the Department of Pathology, University of Szeged, Szeged, Hungary.,

    Bela Ivanyi

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Ivanyi, B. A primer on recurrent and de novo glomerulonephritis in renal allografts. Nat Rev Nephrol 4, 446–457 (2008). https://doi.org/10.1038/ncpneph0854

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