Recurrence of membranoproliferative glomerulonephritis in renal allografts

Clinical course and outcome after kidney transplantation in patients with C3 glomerulonephritis due to CFHR5 nephropathy

BACKGROUND

Complement factor H-related protein 5 (CFHR5) nephropathy is an inherited renal disease characterized by microscopic and synpharyngitic macroscopic haematuria, C3 glomerulonephritis and renal failure. It is caused by an internal duplication of exons 2-3 within the CFHR5 gene resulting in dysregulation of the alternative complement pathway. The clinical characteristics and outcomes of transplanted patients with this rare familial nephropathy remain unknown.

METHODS

This is a retrospective case series study of 17 kidney transplant patients with the established founder mutation, followed-up over a span of 30 years.

RESULTS

The mean (±SD) age of patients at the time of the study and at transplantation was 58.6 ± 9.9 and 46.7 ± 8.8 years, respectively. The 10- and 15-year patient survival rates were 100 and 77.8%, respectively. Proteinuria was present in 33.3% and microscopic haematuria in 58.3% of patients with a functional graft. Serum complement levels were normal in all. 'Confirmed' and 'likely' recurrence of CFHR5 nephropathy were 16.6 and 52.9%, respectively; however, 76.5% of patients had a functional graft after a median of 120 months post-transplantation. Total recurrence was not associated with graft loss (P = 0.171), but was associated with the presence of microscopic haematuria (P = 0.001) and proteinuria (P = 0.018). Graft loss was associated with the presence of proteinuria (P = 0.025).

CONCLUSIONS

We describe for the first time the clinical characteristics and outcome of patients with CFHR5 nephropathy post-transplantation. Despite the recurrence of CFHR5 nephropathy, we provide evidence for a long-term favourable outcome and support the continued provision of kidney transplantation as a renal replacement option in patients with CFHR5 nephropathy.

Long-term cyclophosphamide treatment for recurrent type I membranoproliferative glomerulonephritis after transplantation

The incidence of recurrent type I membranoproliferative glomerulonephritis (MPGN) after renal transplant is approximately 30%, and the rate of graft loss due to recurrent MPGN type I is higher than 50%. The treatment of this disease has not been defined. We report a case of recurrent MPGN type diagnosed 4 months after a cadaveric renal transplantation. The patient was treated with cyclophosphamide and was able to maintain her graft function. Cyclophosphamide was interrupted three times during the course. Each time her renal function deteriorated and her serum albumin decreased. The patient currently has a functional renal graft 3 years after transplantation while receiving low-dose therapy with cyclophosphamide. We suggest treating recurrent type I MPGN with cyclophosphamide while continuing the calcineurin inhibitor and prednisone.