Renal transplantation in anti-neutrophil cytoplasmic antibody vasculitis

Abstract

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) has the propensity to acquire a devastating disease course. Despite the advances in therapeutics, a significant proportion of patients progress to end-stage renal disease (ESRD). Renal transplantation is being increasingly employed in this population, with gradual improvement in outcomes over the years, however, recurrence of disease requires constant surveillance and is associated with graft failure. Areas covered: A structured literature search in PubMed and Medline and abstracts of international conferences was performed to identify cases and cohorts of AAV patients who had undergone renal transplantation for ESRD. The primary objective was to describe the long-term allograft and patient survival and to reflect on current trends in transplantation in AAV and provide recommendations for the phases of pre- and post-transplantation. Expert commentary: Renal transplantation is the treatment of choice for AAV patients with ESRD. The risk of relapse is low with modern immunosuppressive regimes employing mycophenolate mofetil and tacrolimus. It is recommended that the vasculitis be in clinical remission for 12 months prior to transplantation. Although ANCA positivity is not a contraindication for renal transplantation, these patients should be monitored closely for vasculitis relapse post-transplant.

Long‐term outcome of renal transplantation in childhood‐onset anti‐neutrophil cytoplasmic antibody–associated vasculitis

“…Because the effect of MMF in preventing rejection of transplanted kidneys has also been established, MMF is recommended unless it is contraindicated or intolerable. 34 Because recurrence of AAV was not observed in this study, MMF would be recommended for use after RTx.…”

“…However, after RTx, the recurrence rate in patients undergoing combination therapy with antibody induction, TAC, and MMF has been reported to be lower than that in non‐ESRD patients. Because the effect of MMF in preventing rejection of transplanted kidneys has also been established, MMF is recommended unless it is contraindicated or intolerable . Because recurrence of AAV was not observed in this study, MMF would be recommended for use after RTx.…”

Evaluating a Living Donor With Rheumatoid Arthritis for a Recipient With End-Stage Renal Disease From Antineutrophil Cytoplasmic Antibodies Associated Vasculitis

“…One cohort study, in particular, demonstrated that patient and transplant survival was better in AAV compared to nondiabetic patients [45]. Various single and multi-center cohort studies have evaluated the outcomes of renal transplantation in patients with AAV [8,11,12,19,22,[46][47][48][49][50][51] and have shown that the rate of patient and transplant survival in AAV is equal and comparable to control nondiabetic patients. The five-year posttransplant patient survival ranges between 77% and 96%, and the five-year graft survival is between 60% and 100%.…”

Therapeutic apheresis in kidney transplantation: An updated review

“…In the case of a recurrence, the treatment options for remission induction are similar to those of nontransplanted patients. Both cyclophosphamide- and RTX- based induction regimens have shown effectiveness in the treatment of posttransplant relapses[182].…”

“…TPE is recommended, in conjunction with glucocorticoids and either cyclophosphamide or RTX in the setting of relapse manifesting as alveolar hemorrhage, severe segmental necrotizing glomerulonephritis with serum creatinine above 4.0 mg/dL, and concurrent anti-GBM disease[182-184].…”