Recurrent and de novo glomerular disease after renal transplantation - A report from Renal Allograft Disease Registry (RADR)

Introduction. Short-term and long-term results of renal transplantation hav e improved over the past 15 years. However, there has been no change in the prevalence of recurrent and de novo diseases. A retrospective study was in itiated through the Renal Allograft Disease Registry, to evaluate the preva lence and impact of recurrent and de novo diseases after transplantation. Materials and Methods. From October 1987 to December 1996, a total of 4913 renal transplants were performed on adults at the Medical College of Wiscon sin, University of Cincinnati, University of California at San Francisco, U niversity of Louisville, University of Washington, Seattle, and Washington University School of Medicine. The patients were followed for a minimum of 1 year. A total of 167 (3.4%) cases of recurrent and de novo disease were d iagnosed by renal biopsy. These patients were compared with other patients who did not have recurrent and de novo disease (n=4746). There were more me n (67.7% vs, 59.8%, P<0.035) and a higher number of re-transplants (17% vs. 11.5%, P<0.005) in the recurrent and de novo disease group. There was no d ifference in the rate of recurrent and de novo disease according to the tra nsplant type (living related donor vs. cadaver, P=NS). Other demographic fi ndings were not significantly different. Common forms of glomerulonephritis seen were focal segmental glomerulosclerosis (FSGS), 57; immunoglobulin A nephritis, 22; membranoproliferative glomerulonephritis (GN), 18; and membr anous nephropathy, 16. Other diagnoses include: diabetic nephropathy, 19; i mmune complex GN, 12; crescentic GN (vasculitis), 6; hemolytic uremic syndr ome-thrombotic thrombocytopenic purpura (HUS/TTP), 8; systemic lupus erythe matosus, 3; Anti-glomerular basement membrane disease, 2; oxalosis, 2; and miscellaneous, 2. The diagnosis of recurrent and de novo disease was made after a mean period of 678 days after the transplant. During the follow-up period, there were significantly more graft failures in the recurrent disease group, 55% vs. 2 5%, P<0.001, The actuarial 1-, 2-, 3-, 4, and 5-year kidney survival rates for patients with recurrent and de novo disease was 86.5%, 78.5%, 65%, 47.7 %, and 39.8%, The corresponding survival rates for patients without recurre nt and de novo disease were 85.2%, 81.2%, 76.5%, 72%, and 67.6%, respective ly (Log-rank test, P<0.0001). The median kidney survival rate for patients with and without recurrent and de novo disease was 1360 vs. 3382 days (P<0. 0001). Multivariate analysis using the Cox proportional hazard model for gr aft failure was performed to identify various risk factors. Cadaveric trans plants, prolonged cold ischemia time, elevated panel reactive antibody, and recurrent disease were identified as risk factors for allograft failure. T he relative risk (95% confidence interval) for graft failure because of rec urrent and de novo disease was 1.9 (1.57-2.40), P<0.0001. The relative risk for graft failure because of posttransplant FSGS was 2.25 (1.6-3.1), P<0.0 001, for membranoproliferative glomerulonephritis was 2.37 (1.3-4.2), P<0.0 03, and for HUS/TTP was 5.36 (2.2-12.9), P<0.0002. There was higher graft f ailure (64.9%) and shorter half-life (1244 days) in patients with recurrent FSGS. Conclusion. In conclusion, recurrent and de novo disease are associated wit h poorer long-term survival, and the relative risk of allograft loss is dou ble, Significant impact on graft survival was seen with recurrent and de no vo FSGS, membranoproliferative glomerulonephritis, and HUS/TTP.