Allograft diabetic nephropathy may progress to end‐stage renal disease

Abstract

Mesangial expansion and glomerular basement membrane thickening characteristic of diabetic nephropathy recur in diabetic recipients of renal allografts from non-diabetic donors but progression to renal failure is minimally documented. Three female renal allograft recipients (aged 40, 62 and 73 yr), who developed end-stage renal disease (ESRD) due to recurrent diabetic nephropathy (two patients) and de novo diabetes (one patient) are reported. Onset of proteinuria, uncontrolled hypertension, azotemia, renal allograft pathologic findings and the need for hemodialysis were analyzed. None of the kidney donors (one cadaver, two living related) had known diabetes or perturbed glucose metabolism pre-transplantation. The three patients presented had different varieties of diabetes; type 1, type 2 and new onset diabetes after transplantation (NODAT). In each subject, proteinuria was detected by dipstick at a mean of 8.3 yr (range 8-9) post-transplantation and increased to the nephrotic range (3.7-4.8 g/day) inducing hypoalbuminemia and azotemia. A histopathologic diagnosis of allograft diabetic nephropathy was made in a mean of 11.7 yr (range 10-14), based on glomerular basement membrane thickening, nodular and diffuse intercapillary glomerulosclerosis, arteriolosclerosis, and tubular atrophy with marked tubular basement membrane thickening characteristic of advanced diabetic nephropathy. All three patients manifested uremia and resumed hemodialysis. Two patients died from sepsis within 2 months and one patient died 2.5 yr later after resumption of maintenance hemodialysis. We infer that recurrent or de novo diabetic nephropathy in renal allografts follows a clinical decade-long course irrespective of diabetes. Reports of ESRD due to allograft diabetic nephropathy (ADN) have been limited because of shorter survival of diabetic transplant recipients and few kidney biopsies performed in patients with chronic allograft dysfunction. The occurrence of allograft diabetic nephropathy in some, but not all patients, however, suggests that individual genetic variability modulates disease expression.

Having One Kidney Does Not Accelerate the Rate of Development of Diabetic Nephropathy Lesions in Type 1 Diabetic Patients

“…Diabetic nephropathy lesions reoccur in the renal allograft (11)(12)(13)(14)(15)(16)(17). The incidence of clinically significant diabetic nephropathy lesions in transplant kidney biopsy samples ranges from 0.4 to 1.8% (13)(14)(15)(16)(17).…”

“…The incidence of clinically significant diabetic nephropathy lesions in transplant kidney biopsy samples ranges from 0.4 to 1.8% (13)(14)(15)(16)(17). Early pathologic Results of continuous variables are means Ϯ SD or median (range).…”

Rekurrenz der Grundkrankheit nach Nierentransplantation

“…So entwickelt auch nach Jahrzehnten schlechter Blutzuckerkontrolle nur etwa die Hälf-te der Patienten eine diabetische Nephropathie. Rekurrenzen können histologisch schon nach 2,5 Jahren nachweisbar sein, klinisch imponiert nach 6-8 Jahren eine Proteinurie [28]. Ihr Einfluss auf das generelle Transplantatüberleben ist nicht gesichert, auch wenn sie zur chronischen Transplantatnephropathie beitragen kann und Einzelfälle von Transplantatverlust durch diabetische Nephropathie beschrieben wurden [6].…”

Outcomes of De Novo Allograft Diabetic Nephropathy in Renal Allograft Recipients

“…In their case series, 2 cases of recurrent and 1 case of de novo diabetic nephropathy developed ESRD 11,12, and 14 years after transplant. 22 Two of the cases included in present study developed ESRD 15 and 17 years after transplant. Both of these cases had native kidney disease of adult polycystic kidney disease before transplant.…”

“…The reported interval between transplant to the development of de novo diabetic nephropathy ranges from 1 to 24 years. [19][20][21][22] Bhalla and associates have reported 7 cases of de novo diabetic nephropathy and compared them with 9 cases of recurrent diabetic nephropathy. In their study, mean duration for the development of recurrent and de novo ADN were 6.68 ± 3.86 years and 9.93 ± 3.07 years.…”