Risk of Recurrence of Primary Disease
Recurrence of the original kidney disease is a major cause of morbidity and graft loss after transplantation. It is the third most common cause of graft failure at 10 years. The risk, timing, and impact vary widely depending on the underlying disease.
- High-Risk Recurrent Diseases
- Focal Segmental Glomerulosclerosis (FSGS):
Recurs in 20–50% of recipients; the risk increases to 80% if recurrence occurred in a previous graft.
Around 80% of recurrences happen within the first 4 weeks, typically presenting with heavy proteinuria. - Primary Hyperoxaluria:
Recurs in >90% of patients receiving a kidney transplant alone.
Because the metabolic defect is in the liver, oxalate overproduction continues and damages the new kidney unless a combined liver–kidney transplant is performed. - Membranoproliferative Glomerulonephritis (MPGN):
– Type I: recurs in 20–30%
– Type II (dense deposit disease): recurs in >80% - Atypical Hemolytic Uremic Syndrome (aHUS):
Typical (D+) HUS rarely recurs.
Atypical (D–) HUS recurs in 33–56% of adults and 21–28% of children.
Risk reaches 80–100% in patients with Factor H or Factor I mutations.
- Moderate- to Low-Risk Recurrent Diseases
- IgA Nephropathy:
Recurs in 13–53% of patients but usually progresses slowly.
The 10-year risk of graft loss from recurrence is relatively low (~9.7%). - ANCA-Associated Vasculitis:
Recurrence is low (7–17%) if the disease is inactive at the time of transplant. - Anti-GBM Disease:
Clinical recurrence is rare, though histological recurrence may appear in 15–50% of biopsies.
Risk is higher if anti-GBM antibodies are still detectable at transplantation.
- Screening and Diagnosis
Recurrence is suspected when patients develop:
- New-onset proteinuria
- Microhematuria
- Declining GFR
- Disease-Specific Screening:
– FSGS: Daily proteinuria checks for the first week, then weekly for the first month.
– IgA nephropathy / MPGN: Screen for microhematuria every 3 months during the first year. - Biopsy Requirement:
A definitive diagnosis requires a kidney allograft biopsy.
Immunofluorescence and electron microscopy are often needed to distinguish recurrence from rejection or drug toxicity.
- Management Strategies
- Pharmacological:
ACE inhibitors or ARBs are recommended for recurrent glomerulonephritis with proteinuria to help preserve graft function. - Specialized Treatments:
– FSGS or aHUS: Plasma exchange is suggested.
– Recurrent vasculitis or anti-GBM disease: May require high-dose corticosteroids and cyclophosphamide.
• Primary Hyperoxaluria:
Management includes high fluid intake, pyridoxine, and neutral phosphate to reduce oxalate deposition until a liver transplant can be performed.
