Renal transplantation (Tx) is the treatment of choice for
end-stage renal disease. The incidence of acute rejection after renal Tx has decreased because of improving early immunosuppression, but the risk of disease recurrence (DR) is becoming relatively high, with a greater prevalence in children than in adults, thereby increasing patient morbidity, graft loss (GL) and, sometimes, mortality rate. The current overall graft loss to DR is 7-8%, mainly due to primary
glomerulonephritis (70-80%) and inherited
metabolic diseases. The more typical presentation is a recurrence of the full disease, either with a high risk of GL (focal and
segmental glomerulosclerosis 14-50% DR, 40-60% GL; atypical haemolytic uraemic syndrome 20-80% DR, 10-83% GL;
membranoproliferative glomerulonephritis 30-100% DR, 17-61% GL;
membranous nephropathy approximately 30% DR, approximately 50% GL;
lipoprotein glomerulopathy approximately 100% DR and GL;
primary hyperoxaluria type 1 80-100% DR and GL) or with a low risk of GL [
immunoglobulin (Ig)A nephropathy 36-60% DR, 7-10% GL;
systemic lupus erythematosus 0-30% DR, 0-5% GL; anti-neutrophilic cytoplasmic antibody (
ANCA)-associated
glomerulonephritis]. Recurrence may also occur with a delayed risk of GL, such as
insulin-dependent diabetes mellitus,
sickle cell disease, endemic nephropathy, and
sarcoidosis. In other primary diseases, the post-Tx course may be complicated by specific events that are different from overt recurrence:
proteinuria or
cancer in some genetic forms of
nephrotic syndrome, anti-glomerular basement membrane
antibodies-associated
glomerulonephritis (
Alport syndrome,
Goodpasture syndrome), and graft involvement as a consequence of lower urinary tract abnormality or human immunodeficiency virus (HIV) nephropathy. Some other post-Tx conditions may mimic recurrence, such as de novo
membranous glomerulonephritis,
IgA nephropathy, microangiopathy, or isolated specific deposits (
cystinosis,
Fabry disease). Adequate strategies should therefore be added to kidney Tx, such as
donor selection, associated liver Tx, plasmatherapy, specific immunosuppression protocols. In such conditions, very few patients may be excluded from kidney Tx only because of a major risk of DR and repeated GL. In the near future the issue of DR after kidney Tx may benefit from alternatives to organ Tx, such as
recombinant proteins, specific
monoclonal antibodies, cell/gene therapy, and chaperone molecules.