Lethal relapse of Wegener's disease 4 years after successful kidney transplantation

Renal transplantation in antineutrophil cytoplasmic antibody-associated vasculitis

PURPOSE OF REVIEW

This review aims to provide a state-of-the-art perspective on the role of kidney transplantation in cases of end-stage kidney disease due to antineutrophil cytoplasmic antibody (ANCA) vasculitis. We focus on patient and graft survival in recent years, timing of transplant, impact of ANCA status, and relapse of vasculitis in the allograft.

RECENT FINDINGS

Graft and patient outcome compare very favorably with other causes of kidney failure and several recent studies have indicated that these outcomes have improved further in recent years. Relapse of vasculitis posttransplant appears to be lower in the modern era of transplant induction. There may be an excess mortality in those transplanted less than 1 year after induction of vasculitis remission, so it is probably wise to wait for this period before proceeding with the graft. ANCA status at transplant does not appear to influence outcome.

SUMMARY

Kidney transplantation is an excellent treatment for kidney failure due to vasculitis, although one must never lose sight of the cause of the original vasculitic kidney failure in the event of clinical deterioration of an allograft recipient, even if the diagnosis of ANCA vasculitis was many years previously.

Organ transplantation in the vasculitides

Despite important therapeutic improvements, permanent organ failure may develop in primary systemic vasculitides and affect the heart, the lungs, and especially the kidneys. In systemic vasculitides associated with antineutrophil cytoplasmic antibodies (AASV), end-stage renal failure develops in 20% of cases. Renal transplantation became a beneficial option in these patients, with a graft and patient survival comparable to that in nondiabetic patients. This review summarizes the current knowledge on indications and contraindications for renal transplantation in AASV and discusses the impact of posttransplant immunosuppression on the course of the patients.

Rapid recurrence of ANCA-negative pauci-immune vasculitis after cadaveric renal transplantation

We report a patient with renal failure secondary to antineutrophil cytoplasmic autoantibody (ANCA)-negative pauci-immune systemic vasculitis who developed rapid recurrence of vasculitis involving skin, eye, and kidney allograft 1 month after cadaveric renal transplant while being maintained on cyclosporine, mycophenolate mofetil, and prednisolone. Despite early institution of aggressive treatment with plasma exchange, the disease remained uncontrolled and resulted in substantial morbidity and subsequent graft failure within 1 year post-transplantation. This case confirms that ANCA-negative vasculitides may recur in transplanted patients taking mycophenolate mofetil. Transplantation is contraindicated when active disease is evident.

Recurrent ANCA-associated small vessel vasculitis after transplantation: A pooled analysis

BACKGROUND

Recurrent antineutrophil cytoplasmic antibody (ANCA)-associated small vessel vasculitis (ANCA-SVV) after renal transplantation has been described in case series. However, general information regarding the frequency, character, and predictors of recurrent disease after transplantation is currently lacking. We considered the rate of relapse, whether a positive ANCA at the time of transplantation predicted relapse, and whether cyclosporine A prevented recurrent disease.

METHODS

We performed a pooled analysis of published data, added to the experience at the Universities of North Carolina (14 patients) and Lund, Sweden (11 patients). To avoid reporting bias, only case series were included for analysis. Subgroup analysis was performed by disease category (Wegener's granulomatosis, microscopic polyangiitis, or necrotizing crescentic glomerulonephritis) and ANCA staining pattern.

RESULTS

ANCA-SVV recurred in 17.3% of all patients (N = 127), in 20% of cyclosporine A-treated patients (N = 85), and in 25.6% of patients with circulating ANCA at the time of transplantation (N = 39). There was no statistically significant difference in the relapse rate between patients treated and those not treated with cyclosporine A (P = 0.45), between those with and without circulating ANCA at the time of transplant (P = 0.75), or between patients with Wegener's granulomatosis and those with microscopic polyangiitis or necrotizing crescentic glomerulonephritis alone (P = 0.62).

CONCLUSION

There is a substantial relapse rate in the ANCA-SVV population. Therapy with cyclosporine A does not protect against recurrent ANCA-SVV, and the presence of a positive ANCA at the time of transplantation does not preclude transplantation. These conclusions must be substantiated with a prospective study of renal transplantation in patients with ANCA-SVV so as to optimize their management.