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.