Membranous nephropathy (MN) recurs after kidney transplantation in nearly a third of patients with a history of MN but it does not reduce graft survival, investigators reported at the 2022 American Transplant Congress meeting.
Leonardo V. Riella, MD, PhD, of Harvard Medical School and Massachusetts General Hospital in Boston, Massachusetts, and colleagues identified 188 kidney transplant recipients (KTRs) with a history of MN from 16 transplant centers in The Post-Transplant Glomerular Disease (TANGO) Consortium. The median time from MN diagnosis in the native kidney to end-stage kidney disease was 86 months. Of the 188 KTRs, 40 experienced recurrent MN in the kidney graft based on biopsy findings.
MN recurred in 30% of patients within 10 years of transplantation with a median time to recurrence of 4.9 years. The investigators found that the risk for graft loss did not differ significantly between KTRs with and without MN recurrence.
“When effective therapy is administered, disease recurrence does not appear to correlate with worse kidney transplant survival,” Dr Riella explained in an interview with Renal & Urology News. He recommends that transplant physicians perform a biopsy in cases of suspected MN recurrence.
Treatment for recurrent membranous nephropathy after kidney transplantation involved additional renin-angiotensin-aldosterone system (RAAS) blockade in 73% of patients. Among a subset of patients who received B-cell depletion therapy, 60% achieved complete or partial remission. Only 38% of those who did not receive supplemental B-cell depletion therapy experienced remission. Dr Riella recommended that RAAS blockade be prescribed to all patients with post-transplant MN with careful monitoring of kidney function and potassium levels upon initiation. He also advocated rituximab prescription for all patients because in MN pathogenesis autoantibodies form against podocyte antigens. According to Dr Riella, rituximab leads to complete or partial remission in most patients with recurrent MN.
“Early disease recognition is critical to prevent long-term damage to the kidney transplanted organ,” Dr Riella said.
PLA2R antibody titers correlate with MN disease activity, so his team recommends routine testing for PLA2R antibody level titers before and after transplant. They are currently retrieving serum samples from a subset of transplant patients with MN to identify a potential role of PLA2R autoantibodies in predicting and detecting recurrence. They are also investigating novel autoantibodies that may lead to MN recurrence.
Hullekes F, Uffing A, Riella L, Cravedi P. Recurrence of membranous nephropathy after kidney transplantation – TANGO Consortium [abstract]. Am J Transplant. 2022; 22 (suppl 3). Presented at: ATC 2022 meeting; June 4-8; Boston, Massachusetts. Abstract 501.
Uffing A, Hullekes F, Riella LV, Hogan JJ. Recurrent glomerular disease after kidney transplantation: diagnostic and management dilemmas. Clin J Am Soc Nephrol. 2021 Nov;16(11):1730-1742. doi:10.2215/CJN.00280121