Membranous nephropathy (MN) is a common cause of nephrotic syndrome after transplantation and is associated with an increased risk of allograft loss. MN may occur either as a recurrent or as a de novo disease. As in native kidneys, the pathophysiology of the MN recurrence is in most cases associated with antiphospholipid A2 receptor antibodies. However, the posttransplant course has some distinct features when compared with primary MN, including a lower chance of spontaneous remission and a greater requirement for adjuvant immunosuppressive therapy to induce complete remission. Although the efficacy of rituximab in primary MN is now well established, no randomized studies have assessed its effectiveness in MN after transplant, and there are no specific recommendations for the management of these patients. This review aims to synthesize and update the pathophysiology of posttransplant MN, as well as to address unsolved issues specific to transplantation, including the prognostic value of antiphospholipid A2 receptor, the risk of living-related donation, the link between de novo MN and rejection, and different therapeutic strategies so far deployed in posttransplant MN. Lastly, we propose a management algorithm for patients with MN who are planning to receive a kidney transplant, including pretransplant considerations, posttransplant monitoring, and the clinical approach after the diagnosis of recurrence.
1 Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.
2 Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France.
3 Nephrology Department, Hospital del Mar, Barcelona, Spain.
4 Pathology and Cell Biology, Columbia University Medical Center, New York, NY.
5 Division of Nephrology, Boston Medical Center, Boston University School of Medicine, Boston, MA.
6 Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.
Received 18 January 2019. Revision received 25 March 2019.
Accepted 30 March 2019.
M.J.P.S. received funding from the Sociedad Española de Trasplante scholarship. The funding source had no involvement in the study design, the data acquisition, and the writing of the article. The other authors declare no conflicts of interest.
J.L., M.J.P.S., and L.V.R. did the literature search and drafted the article. I.B., L.B., and H.R. gave insight and drafted the article. G.C., C.L., and J.P. revised the article. All authors approved the submission. J.L. and M.J.P.S. contributed equally to the article.
Correspondence: Leonardo V. Riella, MD, PhD, Transplantation Research Center, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, Boston MA 02115. (firstname.lastname@example.org);María José Pérez Sáez, MD, PhD, Nephrology Department, Hospital del Mar, Passeig Maritim 25–29, 08007, Barcelona, Spain. (email@example.com).