Recurrent glomerulonephritis following renal transplantation

Glomerulonephritis (GN*) is the most important cause of end-stage renal disease (ESRD) leading to renal transplantation. In the United Kingdom and Ireland, 27% of renal transplant recipients have GN as their underlying disease. In the Eurotransplant Registry, 31-38% of patients receiving a first graft have GN as the cause of ESRD (J. De Meester and G.G. Persijn, Eurotransplant, Leiden, The Netherlands, personal communication, 1996). Recurrence of nephritis in a transplant and subsequent graft failure were first recognized in 1955, when a patient with ESRD due to vasculitis developed recurrent crescentic GN. Recurrent disease affects 10% of allografts, and 5% of graft loss can be attributed to recurrent GN (3). Analysis of the recent data documented in the United Kingdom Transplant Support Service Authority (UKTSSA) Renal Transplant Audit 1984-1993 suggests that currently 4% of graft loss in adults, and 7% of graft loss in children, is due to recurrent disease. The same rate of graft loss is seen in the Eurotransplant Registry data (J. De Meester and G.G. Persijn, Eurotransplant, personal communication, 1996), with an overall graft loss of 4.4% due to recurrent GN at 5 years after transplantation. However, the frequency of graft loss due to recurrent GN is substantially and significantly increased in grafts from living donors compared with grafts from cadaveric donors (16.2% vs. 4% at 5 years; chi super(2)=12.5, P=0.00046). This difference is most marked in the first year after transplantation. Posttransplantation GN in principle could be caused by truly recurrent GN, by the development of de novo GN in the transplant, or by transplanted GN (from a donor with previously unrecognized GN), and must be distinguished from other causes of posttransplantation glomerulopathy (chronic rejection and cyclosporine induced). Knowledge of the recipient's primary renal disease, the nature of the graft GN, and the absence of primary renal disease in the donor are sine qua nons for the diagnosis of "recurrent glomerulonephritis." In reality, however, all three questions can be answered only in a minority of transplant recipients. The UKTSSA Renal Transplant Audit data reveal that while 1809 graft transplants were performed in recipients with histologically confirmed GN (16% of all grafts), 1271 grafts (11%) were placed in patients with suspected but unconfirmed GN. For the more common nephritides, especially IgA disease, distinguishing recurrence from transplanted GN can b