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RECURRENT DISEASES IN THE TRANSPLANTED KIDNEY
Stephen M. Bonsib, M.D.

I. OVERVIEW

The renal allograft is a precious commodity with the potential to liberate a patient from the dependency of mechanical renal replacement therapy. Although presumably (or hopefully) fairly normal or only minimally damaged at the time harvesting, this organ is the potential target of a wide range of injuries to which it was previously unexposed. These diverse forms of injury are important not only because they affect the potential for allograft survival, but can result in morphologic abnormalities which affect the ease of biopsy interpretation.

FORMS OF ALLOGRAFT INJURY

Ischemia/perfusion injury during graft placement Rejection
Anatomic injury to vessels or lower urinary tract De novo disease
Drug toxicities Recurrent disease

The potential for recurrent disease to affect the allograft was recognized by Hume, et al. in the first series of human "homotransplants" published in 1955. A patient with PAN developed recurrent crescentic GN in the allograft prompting the authors to write "Our results appear to indicate 1) that the disease of the patient can, under some circumstances, influence the course of the transplant..." The risk of recurrent disease to the allograft in identical twins transplanted for glomerulonephritis appeared particularly great, prompting Glassock, et al. in 1968 to state, "The possibility of recurrence of the original disease process in the transplanted kidney may remain a serious threat to the long term survival of renal transplant recipients." The concern has not materialized. Although recurrent disease affects 10% of allografts, it causes graft loss in only 2-4% (up to 7% of pediatric patients). Rejection (or chronic transplant nephropathy) is the leading cause of allograft loss.

Recurrent diseases pose a challenge in morphologic diagnosis. Their recognition first requires knowledge of the original disease as classified by native kidney biopsy. Since glomerulonephritis is the most common recurrent disease, the prospect of recurrent disease also creates a dilemma regarding optimum biopsy handling in an environment where control of costs is increasingly emphasized and use of ancillary studies such as immunofluorescence and electron microscopy are increasingly scrutinized.

The risk of recurrent disease and its implications vary substantially between the various causes of end stage renal disease (ESRD). Furthermore, children and adults differ in their etiologic profile of ESRD (illustrated below).

Cause of ESRD Adult Child Recurrence Rate Graft Loss
Diabetes 36% 1.4% 100% <5%
Hypertension 30% 5.5% ? <5%
Glomeruloephritis 15% 44% 20-30% 10%
Cystic Disease 3% **4% 0% 0%
Interstitial Disease *3% 4% variable variable
Obstuctive Disease 2% **8% variable variable
Hemolytic-Uremic Syndrome 0% 5% common 40-50%
Metabolic disease oxalosis 0% 1.3% 90%
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*Analgesic nephropathy is a major cause of ESRD outside of the U.S.
**Developmental anomalies and cystic diseases constitute 22% of ESRD

Continue with Do Common Renal Diseases of Adults Recur Commonly?

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Last Modified: March 21, 1996 9:19:35 AM

 

 

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