Recurrence of anti‐neutrophil cytoplasmic antibody vasculitis in the kidney allograft

Abstract

We report a case of recurrent anti-cytoplasmic neutrophil antibody (ANCA)-associated vasculitis post kidney transplantation. A 60-year-old woman underwent uncomplicated deceased-donor kidney transplantation for end-stage renal disease (ESRD) secondary to myeloperoxidase-specific ANCA-associated vasculitis, after six years of haemodialysis, and clinical remission. Immunosuppression was with tacrolimus/mycophenolate and prednisolone after basiliximab induction therapy. Five weeks post-transplantation, an allograft biopsy, done for a rising creatinine and glomerular haematuria, revealed pauci-immune crescentic glomerulonephritis. This was treated with pulse methylprednisolone, increase in maintenance prednisolone, 7 sessions of plasma exchange, and replacement of mycophenolate with cyclophosphamide. Tacrolimus was continued throughout. After 3 months of therapy a repeat allograft biopsy showed quiescent vasculitis. The cyclophosphamide was then ceased, and mycophenolate reinstituted. The patient has maintained clinical and histological stability. Reported rates of ANCA-associated vasculitis recurrence post-kidney transplantation have varied but are low compared with other types of glomerulonephritis and seemed to have further declined in the era of modern immunosuppression. Given the low recurrence rate and excellent outcomes in suitable patients, kidney transplantation remains the optimal form of renal replacement therapy for ESRD due to ANCA-associated vasculitis. Whilst re-introduction of cyclophosphamide has been the mainstay of therapy, additional reported successful therapeutic strategies have included pulse methylprednisolone, plasma exchange and rituximab. Further study on the most effective and safest treatment options would be of use given the current paucity of data in this area.