The Clinicopathologic Characteristics of Recurrent Lupus Nephritis Post-Transplant Using Surveillance and Indication Biopsies

Introduction

The incidence of recurrent lupus nephritis (RLN) after kidney transplantation (KTx) varies with higher rates of RLN reported in surveillance biopsy-based studies (vs. clinically indicated biopsies).

Methods

We present a multisite retrospective study evaluating surveillance and clinically indicated biopsies in 209 first KTx recipients who had native lupus disease.

Results

Of the 112 patients with satisfactory material for comprehensive histology, RLN was observed in 40 (35.7%). We describe the pathology of histologic RLN (HRLN; 40%) and clinical RLN (CRLN; 60%). African Americans had the highest recurrence rate (48.3%) of whom 50% had CRLN. HRLN was noted as early as 18 days, with early diagnosis (< 3 months of follow-up time) using surveillance biopsies. Mesangioproliferative pattern of glomerular injury (^˷ class II lupus nephritis [LN] by International Society of Nephrology/Renal Pathology Society) was the most frequent pattern of RLN. IgG dominance or codominance was the most frequent Ig staining pattern. A full-house pattern of staining was only seen in 6% of HRLN and 37% of CRLN. C4d stain, as a stand-alone immunofluorescence (IF) test, was performed in the index renal allograft biopsy in 37.5% of patients, with RLN, prompting evaluation with a full IF panel. Electron microscopy (EM) confirmed the findings on IF. Graft loss because of lupus-associated pathology was observed in 50% of RLN subjects, of which thrombotic microangiopathy was seen in 25%.

Conclusion

Our study demonstrates that RLN is frequent and may be clinically quiescent. Sequential biopsy evaluation provided an opportunity to study the natural evolution of the disease.