Arthritis & Rheumatism, Volume 60,
October 2009 Abstract Supplement
The 2009 ACR/ARHP Annual Scientific Meeting
Philadelphia October 16-21, 2009.
Renal Transplantation in Wegeners Granulomatosis and Microscopic Polyangiitis
Geetha, Duvuru, Haas, Mark, Kraus, Edward S., Rabb, Hamid, Seo, Philip
ANCA-associated vasculitis (AAV) is an important cause of end-stage renal disease. How modern immunosuppressive regimens influence outcomes among patients with Wegener's granulomatosis (WG) and microscopic polyangiitis (MPA) after renal transplant is unclear.
We conducted a retrospective cohort study of patients who underwent renal transplant at The Johns Hopkins Hospital between 1999 and 2008. Analysis was performed using STATA 9.0 (College Park, TX).
A total of 24 patients with end stage renal disease due to AAV received a kidney transplant at the Johns Hopkins Hospital between 1999 and 2008. Follow-up data are available for 11 patients with WG and 6 patients with MPA who were followed for 799 patients-months of observation. The majority of these patients were Caucasian (82.4%) with an approximately equal numbers of men and women (8:10). 9/11 of the patients with WG were PR3-ANCA positive, while 5/6 of the patients with MPA were MPO-ANCA positive. Two of the patients with MPA also had anti-GBM antibodies.
All but one patient (94.1%) had renal involvement at the time of their vasculitis diagnosis; 5 WG patients (45.5%) and 2 MPA patients (33.3%) presented with end-stage renal disease. Most patients in this cohort received first renal transplants (72.2%) from a living-related donor (70.6%).
At the time of transplant, patients with WG were older (median age 51.5 versus 39 years) and carried a diagnosis of vasculitis for longer (51 months versus 18.5 months) than patients with MPA, although the difference was not statistically significant (P=0.2 for each comparison).
Most patients (10/16) were ANCA-negative at the time of transplant; none of these patients have experienced a vasculitis flare during the observation period. There was one flare per 22 patient-years of observation; all flares occurred in patients who were ANCA-positive: one patient with WG and one with MPA had recurrent glomerulonephritis affecting the transplanted kidney; one additional WG patient experienced a non-renal vasculitis flare.
All patients received maintenance immunosuppression with a mycophenolate mofetil/tacrolimus-based regimen. There were no episodes of rejection among patients with MPA. Two patients with WG had an episode of rejection; both occurred in patients who were highly sensitized and had received treatment with rituximab, plasmapheresis, and IVIG prior to transplant.
The median serum creatinine following transplant was 1.1 mg/dL. The median serum creatinine at the time of last follow-up was 1.3 mg/dL among patients with WG and 1.0 mg/dL among patients with MPA (P=0.1)
Renal transplantation is effective in patients with WG and MPA. The combination of mycophenolate mofetil and tacrolimus is effective at preventing both disease relapse and rejection for most patients with AAV. Patients who are ANCA-negative have particularly good outcomes; patients who are ANCA-positive may benefit from more aggressive maintenance immunosuppression. Whether patients with MPA may have better outcomes after transplant than patients with WG merits further study.
To cite this abstract, please use the following information:
Geetha, Duvuru, Haas, Mark, Kraus, Edward S., Rabb, Hamid, Seo, Philip; Renal Transplantation in Wegeners Granulomatosis and Microscopic Polyangiitis [abstract]. Arthritis Rheum 2009;60 Suppl 10 :1847