Similar incidence of graft glomerulonephritis in recipients with definitively diagnosed glomerulonephritis and those with unknown etiology: a retrospective observational study

Figures & data

Figure 1. Flow chart of selection of the study population. GN: glomerulonephritis; uESRD: unknown causes of end-stage renal disease; RTA: renal tubular acidosis; DN: diabetic nephropathy; HBV: hepatitis B virus.

Table 1. Baseline data for kidney transplant recipients.

	Total cohort (N = 473)	GN group (N = 119)	uESRD group (N = 354)	p
Clinical features pre-KTx
Age at KTx, years	35[28,44]	35[28,44]	35[27,44]	0.76
Male, n(%)	333 (70%)	71 (60%)	262 (74%)	0.003
BMI, kg/m^2	21[19,23]	21[18,23]	21[19,23]	0.18
Relatives with kidney disease (3 generations), n(%)	20 (4%)	5(4%)	15(4%)	0.99
HBV, n(%)	11(2%)	0 (0%)	11 (3%)	0.07
Autoantibody, n(%)
AECA+	61 (13%)	13 (11%)	48 (14%)	0.46
ANA+	8 (2%)	4 (3%)	4 (1%)	0.22
Anti-GBM antibody+	2 (0.4%)	1 (0.8%)	1 (0.3%)	>0.99
Anti-PLA2R antibody+	1/126 (0.8%)	0/31(0%)	1/95 (1%)	>0.99
24 h urinary protein, g/24 h	1.8[0.9,3.5]	1.9[0.9,3.8]	1.7[0.9,3.3]	0.22
FPG, mmol/L	4.9[4.5,5.4]	4.86[4.5,5.4]	4.9[4.5,5.4]	0.92
Type of dialysis, n(%)				<0.001
Without dialysis	14 (3%)	8 (7%)	6 (2%)
HD	367 (78%)	78 (66%)	289 (82%)
PD	92 (20%)	33 (28%)	59 (17%)
The duration of dialysis, mos	24[14,49]	24[10,52]	24[15,48]	0.76
Given a blood transfusion pre-KTx, n(%)	65 (14%)	13 (11%)	52 (15%)	0.30
History of pregnancy pre-KTx, n(%)	72 (50%)	24 (49%)	48 (50%)	0.91
Surgical information
Donor type, n(%)				0.04
LD	180 (28%)	36 (30%)	144 (41%)
DD	293 (62%)	83 (70%)	210 (59%)
HLA mismatches				0.33
0	10 (2%)	2 (2%)	8 (2%)
1–3	191 (40%)	43 (36%)	148 (42%)
4–6	225 (48%)	65 (55%)	160 (45%)
Unknown	47 (10%)	9 (8%)	38 (11%)
PRA, n(%)				0.46
Ι+	33 (7%)	6 (5%)	27 (8%)
II+	21 (4%)	3 (3%)	18 (5%)
Ι, II+	26 (6%)	6 (5%)	20 (6%)
Induction therapy, n(%)				0.81
IL-2R	214 (45%)	55 (46%)	159 (45%)
ATG	259 (55%)	64 (54%)	195 (55%)
Immunosuppression regimens, n(%)				0.47
FK506 + MMF + Prednisone	334 (71%)	79 (66%)	255 (72%)
CsA + MMF + Prednisone	8 (2%)	3 (3%)	5 (1%)
FK506 + MPS + Prednisone	116 (25%)	32 (27%)	84 (24%)
FK506 + Rapa + Prednisone	1 (0.2%)	0 (0%)	1 (0.3%)
CsA + MPS + Prednisone	8 (2%)	4 (3%)	4 (1%)
FK506 + MZR + Prednisone	6 (1%)	1 (1%)	5 (1%)
Cold ischemia time, min	480[180,600]	600[180,600]	480[180,600]	0.20
Warm ischemia time, min	3[3,3]	3[3,3]	3[3,3]	0.02
CDC(%)	5[4,6]	5[4,7]	5[4,6]	0.14
Duration of operation, min	190[170,220]	195[180,220]	190[170,220]	0.41
Adverse events^#, n(%)
Infection	39 (8%)	15 (13%)	24 (7%)	0.05
Rejection	37 (8%)	10 (8%)	27 (8%)	0.79
DGF, n(%)	29 (6%)	7 (6%)	22 (6%)	0.90
Follow-up time post-KTx, mos	50[34,66]	49[35,62]	51[34,67]	0.30

^#, within 1 month post-KTx; N: number; GN: glomerulonephritis; uESRD: unknown causes of end-stage renal disease; KTx: kidney transplantation; BMI: body mass index; HBV: hepatitis type B; AECA: anti-endothelial cell anti-body; ANA: antinuclear antibodies; GBM: glomerular basement membrane; FPG: fasting plasma glucose; HD: hemodialysis; PD: peritoneal dialysis; mos: months; LD: living donor; DD: deceased donor; HLA: human leukocyte antigen; PRA: panel reactive antibody; ATG: antithymocyte globulin; min: minute; FK506: tacrolimus; MMF: mycophenolate mofetil; Pred: prednisone; RAPA: rapamycin; CsA: cyclosporin A; MPS: mycophenolate sodium; CDC: complement dependent cytotoxity; DGF: delayed graft function

Figure 2. The incidence of graft GN among groups. (A) the cumulative incidence of graft GN between GN group and uESRD group; (B) the cumulative incidence of graft GN after receiving LD or DD transplant in recipients with diagnosed GN or uESRD; (C) Incidence density of graft GN in KTRs among groups. GN: glomerulonephritis; uESRD: unknown causes of end-stage renal disease; LD: living donor; DD: deceased donor.

Figure 3. The distribution of GN subtypes (A), diagnosis time (B), and incidence of abnormal urine test (C) in GN group and uESRD group. ^#Distribution of glomerular disease subtypes in GN group and uESRD group after transplantation; *Time of GN diagnosis in GN group and ESRD group; ^♦ Occurrence of postoperative abnormal urine test in graft GN KTRs in GN group and uESRD group. LN, lupus nephritis; HSPN: Henoch–Schonlein purpura nephritis; MesGN, mesangial glomerulonephritis; FSGS, focal segmental glomerulosclerosis; PGNMID, proliferative glomerulonephritis with monoclonal IgG deposits; MN, membranous nephropathy; IgMN, IgM nephropathy; ICGN, Immune complex glomerulonephritis; GN, glomerulonephritis; uESRD, unknown causes of end-stage renal disease.

Table 2. Analysis of risk factors of graft GN.

Variable	Univariate analysis		Multivariate analysis
	OR(95%CI)	p	OR(95%CI)	p
Male	3.065(1.568–5.991)	0.001	3.114(1.562–6.206)	0.001
Age at KTx	0.957(0.933–0.982)	0.001	0.968(0.939–0.997)	0.028
BMI	1.009(0.939,1.085)	0.806
Age at onset <18 years	1.220(0.564,2.639)	0.614
Relatives with kidney disease (three generation)	1.240(0.403,3.812)	0.707
HBV	1.094(0.232,5.162)	0.91
ANA + pre-KTx	0.698(0.085,5.753)	0.738
24 h urinary protein	0.925(0.799,1.071)	0.298
Type of dialysis (compared with HD)		0.816
PD	0.866(0.461,1.627)	0.655
Without dialysis	1.316(0.357,4.854)	0.68
Given a blood transfusion pre-KTx	0.878(0.427,1.806)	0.723
ACEA + pre-KTx	2.603(1.420–4.773)	0.002	2.942(1.545–5.600)	0.001
Induction therapy	1.185(0.732,1.918)	0.49
LD	2.457(1.508–4.004)	<0.001	1.585(0.686,3.665)	0.281
Warm ischemia time	0.877(0.597,1.291)	0.507
Cold ischemia time	0.998(0.998–0.999)	0.002	1.000(0.998,1.001)	0.752
Scr at discharge	1.131(0.826,1.549)	0.442
Given a blood transfusion post-KTx	0.914(0.487,1.716)	0.781

BMI: body mass index; GN: glomerulonephritis; HBV: hepatitis type B; AECA: anti-endothelial cell anti-body; ANA: antinuclear antibodies; LD: living donor; DGF: delayed graft function; Scr: serum creatinine

Table 3. Comparison of clinical characteristics after propensity score matching.

	GN group (N = 81)	uESRD group (N = 81)	p
Clinical features pre-KTx
Age at KTx, years	35 [28,46.5]	36 [28,48]	0.935
Male, n (%)	56 (69.1%)	58 (71.6%)	0.731
BMI, kg/m [2]	20.7 [18.5,23.4]	21.7 [19.8,23.9]	0.042
Have relatives with kidney disease (3 generation), n(%)	4 (5%)	3 (4%)	0.699
HBV, n(%)	0 (0%)	2 (3%)	0.477
Autoantibody, n(%)
AECA+	10 (12%)	12 (15%)	0.646
ANA+	2 (3%)	2 (3%)	>0.99
anti-GBM antibody+	1 (1%)	0 (0%)	>0.99
24 h urinary protein(g/24 h)	2.11 [1.04,3,56]	1.80 [0.94,3.28]	0.227
FPG, mmol/L	4.87 [4.53,5.34]	4.89 [4.36,5.33]	0.906
Type of dialysis, n(%)			0.254
Without dialysis	6 (7%)	3 (4%)
HD	55 (68%)	64 (79%)
PD	20 (25%)	14 (17%)
The duration of dialysis, mos	22.1 [9.8,46.7]	24.1 [17.1,36,7]	0.287
Given a blood transfusion pre-KTx, n(%)	10 (12%)	7 (9%)	0.442
History of pregnancy pre-KTx, n(%)	13 (16%)	13 (16%)	0.768
Surgical information
Donor type, n(%)			0.627
LD	32 (40%)	29 (36%)
DD	49 (61%)	52 (64%)
HLA mismatches			0.571
0	1 (1%)	1 (1%)
1–3	36 (44%)	29 (36%)
4–6	39 (48%)	42 (52%)
Unknown	5 (6%)	9 (11%)
PRA, n(%)			0.149
Ι+	6 (7%)	5 (6%)
II+	2 (3%)	9 (11%)
Ι, II+	4 (5%)	2 (3%)
Induction therapy, n(%)			0.343
IL-2R	39 (48%)	33 (41%)
ATG	42 (52%)	48 (59%)
Immunosuppression regimens, n(%)			0.563
FK506 + MMF + Prednisone	68 (84%)	68 (84%)
CsA + MMF + Prednisone	3 (4%)	1 (1%)
FK506 + MPS + Prednisone	10 (12%)	11 (14%)
FK506 + Rapa + Prednisone	0 (0%)	0 (0%)
CsA + MPS + Prednisone	0 (0%)	0 (0%)
FK506 + MZR + Prednisone	0 (0%)	1 (1%)
Cold ischemia time, min	600 [180,600]	540 [180,600]	0.945
Warm ischemia time, min	3 [3,3]	3 [3,3]	0.960
CDC(%)	5 [4,7]	5 [4,7]	0.935
Duration of operation, min	190 [178,228]	190 [170,220]	0.621
Adverse events^#, n(%)
Infection	11 (14%)	6 (7%)	0.200
Rejection	6 (7%)	8 (10%)	0.576
DGF, n(%)	1 (1%)	6 (7%)6	0.122
Follow-up time post-KTx, mos	49 [35,66]	48 [31,62.5]	0.599

#, within 1 month post-KTx; N: number; GN: glomerulonephritis; uESRD: unknown causes of end-stage renal disease; KTx: kidney transplantation; BMI: body mass index; HBV: hepatitis type B; AECA: anti-endothelial cell anti-body; ANA: antinuclear antibodies; GBM: glomerular basement membrane; FPG: fasting plasma glucose; HD: hemodialysis; PD: peritoneal dialysis; mos: months; LD: living donor; DD: deceased donor; HLA: human leukocyte antigen; PRA: panel reactive antibody; ATG: antithymocyte globulin; min: minute; FK506: tacrolimus; MMF: mycophenolate mofetil; Pred: prednisone; RAPA: rapamycin; CsA: cyclosporin A; MPS: mycophenolate sodium; CDC: complement dependent cytotoxity; DGF: delayed graft function.

Figure 4. The incidence of graft GN (A), abnormal urine test (B), and incidence density (C) between groups after matching. GN: glomerulonephritis; uESRD: unknown causes of end-stage renal disease; KTx: kidney transplantation.

El-Zoghby ZM, Stegall MD, Lager DJ, et al. Identifying specific causes of kidney allograft loss. Am J Transplant. 2009;9(3):527–535. doi: 10.1111/j.1600-6143.2008.02519.x.

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Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.