High exposure to tacrolimus is associated with spontaneous remission of recurrent membranous nephropathy after kidney transplantation

Buxeda, Anna; Caravaca Fontán, Fernando; Vigara, Luis Alberto; Pérez Canga, José Luis; Calatayud, Emma; Coloma, Ana; Mazuecos, Auxiliadora; Rodrigo Calabia, Emilio; Sancho, Asunción; Melilli, Edoardo; Praga, Manuel; Pérez-Sáez, María José; Pascual Santos, Julio

doi:http://dx.doi.org/10.1093/ckj/sfad077

High exposure to tacrolimus is associated with spontaneous remission of recurrent membranous nephropathy after kidney transplantation

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Buxeda A, Caravaca-Fontán F, Vigara LA, Pérez-Canga JL, Calatayud E, Coloma A, et al. High exposure to tacrolimus is associated with spontaneous remission of recurrent membranous nephropathy after kidney transplantation. Clin Kidney J. 2023 Apr 12;16(10):1644-55. DOI: 10.1093/ckj/sfad077

Abstract

Introduction: We aimed to characterize the incidence and clinical presentation of membranous nephropathy (MN) after kidney transplantation (KT), and to assess allograft outcomes according to proteinuria rates and immunosuppression management. Methods: Multicenter retrospective cohort study including patients from six Spanish centers who received a KT between 1991-2019. Demographic, clinical, and histological data were collected from recipients with biopsy-proven MN as primary kidney disease (n = 71) or MN diagnosed de novo after KT (n = 4). Results: Up to 25.4% of patients with biopsy-proven MN as primary kidney disease recurred after a median time of 18.1 months posttransplant, without a clear impact on graft survival. Proteinuria at 3-months post-KT was a predictor for MN recurrence (rMN, HR 4.28; P = 0.008). Patients who lost their grafts had higher proteinuria during follow-up [1.0 (0.5-2.5) vs 0.3 (0.1-0.5) g/24 h], but only eGFR after recurrence treatment predicted poorer graft survival (eGFR < 30 ml/min: RR = 6.8). We did not observe an association between maintenance immunosuppression and recurrence diagnosis. Spontaneous remission after rMN was associated with a higher exposure to tacrolimus before recurrence (trough concentration/dose ratio: 2.86 vs 1.18; P = 0.028). Up to 94.4% of KT recipients received one or several treatments after recurrence onset: 22.2% rituximab, 38.9% increased corticosteroid dose, and 66.7% ACEi/ARBs. Only 21 patients had proper antiPLA2R immunological monitoring. Conclusions: One-fourth of patients with biopsy-proven MN as primary kidney disease recurred after KT, without a clear impact on graft survival. Spontaneous remission after rMN was associated with a higher exposure to tacrolimus before recurrence.