Post-Transplant Glomerulonephritis: Challenges and Solutions

Figures & data

Table 1 General Characteristics, Challenges, and Solutions of Post-Transplant Glomerulonephritis

Glomerulopathy	Challenges	Solutions
IgA Nephropathy (IgAN)	Recurrence: 8–53% Risk factors for recurrence: - Living donors, younger recipients, steroid-avoidance immunosuppression, absence of induction therapy. Presentation of recurrence: - Graft dysfunction - Absence of hematuria at diagnosis is frequent	Screening and monitoring: - Creatinine, albuminuria, proteinuria, hematuria - Biomarkers: IgA, IgA-IgG, IgA-soluble CD89 - Once in the first month, every 3 months in the first year, then annually Treatment: - ACEi, ARB, steroids
Membranous Nephropathy (MN)	Recurrence: up to 40% Risk factors for recurrence: - High levels of proteinuria, detected anti-PLA2R before transplantation. Presentation of recurrence: - Proteinuria, graft dysfunction - Association of de novo MN with acute antibody-mediated rejection	Screening and monitoring: - Creatinine, albuminuria, proteinuria - Biomarker: anti-PLA2R - Once in the first month, every 3 months in the first year, then annually Treatment: - ACEi, ARB, rituximab - Identifying and treating underlying triggers on the secondary forms
Focal Segmental Glomerulosclerosis (FSGS)	Recurrence: 4–66% Risk factors for recurrence: - Younger age at transplantation, higher level of proteinuria before transplantation, related donor, nephrectomy of native kidneys, recurrence in a previous allograft, hypoalbuminemia at presentation, absence of family history of FSGS. Presentation of recurrence: - Proteinuria	Screening and monitoring: - Genetic testing, creatinine, albuminuria, proteinuria - biomarker: suPAR, CLC-1, AT1R-Ab, anti-CD40, IL-13 - Before transplantation, daily for 1 week, weekly for 4 weeks, every 3 months for 1 year, then annually Treatment: - Plasmapheresis - ACEi, ARB, rituximab - Identifying and treating underlying triggers on the secondary forms
Immune complex and complement-mediated membranoproliferative glomerulonephritis (MPGN)	Recurrence: 27% to 65% Risk factors for recurrence: - Living-related donors, younger age at MPGN diagnosis, low serum C3 levels, higher proteinuria Presentation at recurrence: - Hematuria and proteinuria - Higher recurrence rate in the complement-mediated MPGN	Screening and monitoring: - Proteinuria, hematuria, serum complement levels - Once in the first month, every 3 months in the first year, then annually Treatment: - Therapeutic strategies targeting the components of the complement pathways - Identification and treatment of the underlying triggers
Viral glomerulopathies	Immunosuppressive therapy increases the risk of viral infections and its complications	- Pre-transplant treatment of chronic viral infections - Monitoring and treating post-transplant viral infections

Abbreviations: Anti-PLA2R, antibody against M-type phospholipase A2 receptor; ACEi, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blockers; suPAR, serum urokinase plasminogen activator receptor; CLC-1, cardiotrophin-like cytokine-1; AT1R-Ab, anti-angiotensin II type 1 receptors; IL-13, interleukin-13.