NDT Advance Access originally published online on July 13, 2009
Nephrology Dialysis Transplantation 2009 24(10):3219-3225; doi:10.1093/ndt/gfp347
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Renal transplantation in systemic vasculitis: when is it safe?
1 Renal Institute of Birmingham, School of Immunity, Infection and Inflammation, University of Birmingham, Birmingham, UK 2 Department of Nephrology and Transplantation, Imperial College Healthcare Trust, London, UK 3 Regional Nephrology unit, Belfast City Hospital 4 Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
Correspondence and offprint requests to: Lorraine Harper; E-mail: l.harper{at}bham.ac.uk
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Abstract |
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Background. There are no clear guidelines on renal transplantation in patients with antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis.
Methods. We undertook a survey of transplant centres across Europe to assess whether there was consensus about how to manage transplantation in patients with vasculitis. We then identified 107 renal allograft recipients whose primary disease was systemic vasculitis and assessed their outcome post-transplant.
Results. All questionnaire respondents felt that vasculitis should be in remission at transplantation, 16% believed that ANCA should be negative pre-transplant and 40% felt that one should wait >12 months after remission before transplanting. Remission was defined by all as an absence of clinical symptoms of vasculitis, but three respondents (13%) also required a negative ANCA test. Overall graft survival was 70% after 10 years (95% C.I. 58–82). A total of 30 (41% of those with known ANCA status) were ANCA-positive peri-transplantation, while 15 (14%) were transplanted <1 year post-remission. Severe vasculopathy occurred more frequently in ANCA-positive recipients (odds ratio 4.4, 95% C.I. 1.1–16.8, P < 0.05), although causation cannot be determined from this study. Vasculopathy significantly reduced 10-year graft survival to 47% (P < 0.05). However, ANCA status per se was not significantly associated with graft failure. The strongest predictor of death was transplantation <1 year post-vasculitis remission on both univariate and multivariate analysis (hazard ratio 2.3, P < 0.05).
Conclusions. In conclusion, circulating ANCA at transplant was associated with the development of vascular lesions in the graft but was not significantly correlated with graft survival. Most grafts were lost due to patient death, which was more likely if transplantation occurred <12 months following induction of remission of ANCA-positive vasculitis.
Keywords: ANCA; survey; transplantation; vasculitis; vasculopathy
* The last two authors contributed equally to this work.
Received for publication: 10. 3.09
Accepted in revised form: 23. 6.09