Recurrent lupus nephritis (LN) can manifest suddenly even years after kidney transplantation and without the typical laboratory indicators of lupus flare, investigators reported at the virtual 2021 National Kidney Foundation Spring Clinical Meetings.
Sreedevi Koppisetti Jenigiri, MD, of the University of Iowa Hospitals and Clinics in Iowa City, and colleagues described the case of a 39-year-old woman who developed kidney failure from LN in 2006. Prior to transplantation, a native kidney biopsy showed global sclerosis with immune complex glomerulonephritis that correlated with positive serum antinuclear (ANA) and anticardiolipin antibodies (ACA).
The patient received a kidney transplant from a related living donor in February 2007. The only post-transplant complication, Banff grade IIA acute cellular rejection, occurred at 1 month and was successfully treated with steroids. The patient’s serum creatinine stabilized at 1.2 to 1.3 mg/dL.
For maintenance immunosuppression, the patient received tacrolimus, mycophenolate mofetil (MMF), and prednisone. MMF was replaced with azathioprine during an uneventful pregnancy in 2011.
Over the years, her serum creatinine level increased slightly but stabilized at 1.4 to 1.6 mg/dL. Then, in July 2019, her serum creatinine level suddenly spiked to 3.9 mg/dL accompanied by proteinuria and microscopic hematuria. Other relevant parameters were at normal levels, including platelets, complement, ANA, ANCA, and double-stranded DNA.
Biopsy results indicated thrombotic microangiopathy, diffuse proliferative glomerulonephritis with focally crescentic LN, and a full house pattern on immunofluorescence. Despite treatment with intravenous steroids and cyclophosphamide, the patient’s allograft function deteriorated, and she required dialysis by November 2019.
According to Dr Jenigiri’s team, additional studies are needed to understand why LN recurs in patients, such as this woman, with long-term stable renal function.
Koppisetti Jenigiri S, Patel J, Thomas C, Kuppachi S. Rapid renal allograft failure following recurrence of lupus nephritis 12 years after renal transplant. Presented at the virtual National Kidney Foundation 2021 Spring Clinical Meetings, April 6-10, 2021. Poster 83.