LUPUS nephritis recurrence after kidney transplant may occur silently and more frequently than previously recognized, according to a new multisite retrospective study using both surveillance and indication biopsies.
In this analysis of 209 patients with prior lupus nephritis who received a first kidney transplant, 112 had biopsy material suitable for detailed histologic assessment. Among these, recurrent lupus nephritis (RLN) was identified in 35.7% of cases. The study distinguished between histologic recurrence (HRLN) and clinical recurrence (CRLN), with 40% and 60% of RLN cases falling into these categories, respectively.
African American patients had the highest recurrence rate, with nearly half (48.3%) experiencing RLN. Of these, half were diagnosed based on clinical signs. Notably, some cases of HRLN were identified as early as 18 days post-transplant, underscoring the value of early surveillance biopsies in detecting clinically silent disease.
Mesangioproliferative glomerular injury, aligning with class II lupus nephritis, emerged as the most common histologic pattern. IgG-dominant or codominant staining was frequently observed, while the classical “full-house” immunofluorescence pattern, traditionally associated with lupus nephritis, was present in only 6% of HRLN and 37% of CRLN cases.
C4d staining, although not used universally, prompted broader immunofluorescence testing in 37.5% of RLN patients and was supported by electron microscopy findings. The study also revealed that lupus-associated pathology accounted for half of all graft losses in RLN patients, with thrombotic microangiopathy identified in 25% of those cases.
These findings highlight the potential for RLN to progress unnoticed without routine surveillance. The authors emphasize that sequential biopsies provide critical insight into disease evolution post-transplant and suggest a potential role for expanded monitoring strategies in high-risk populations.
Reference:
Gonzalez Suarez ML et al. The Clinicopathologic Characteristics of Recurrent Lupus Nephritis Post-Transplant Using Surveillance and Indication Biopsies. Kidney Int Rep. 2025;10(6):1829-1842.
