Recurrent disease after renal transplantation

Summary Recurrent disease after renal transplantation is assuming a greater relative importance, as rejection is less frequently the cause of graft failure. Recurrence proven using careful clinical and morphologic criteria has accounted for less than 2% of graft failures but probably occurs up to 10 times more frequently and may take many years to contribute to graft failure. No primary cause of renal failure poses an absolute contraindication to at least one attempt at transplantation, although in patients with oxalosis, special consideration of the risk is needed. The risk of recurrence appears to be increased in a number of conditions, particularly glomerulonephritis, where the clinical course of the initial renal failure has been short and relentless. In this circumstance, it may be desirable to delay transplantation in order to allow the primary condition to stabilise or subside. Special recommendations regarding transplantation are emerging in a number of primary conditions. Systemic activity of disease should be allowed to subside in anti-GBM nephritis, Schonlein-Henoch purpura, and SLE. Avoidance of primary nonfunction is important in oxalosis. Care in the choice (or the avoidance) of living related donors may be wise in HUS and Fabry's disease, and in the second graft for those with recurrent focal and segmental glomerulosclerosis. Where a new kidney is given to a patient with a systemic condition and the kidney is a “passive bystander,” recurrence is usually predictable, and the time course of clinical expression of recurrence is often similar to that seen initially. Examples are type I diabetes, monoclonal gammopathy, sickle cell disease, and oxalosis. An exception is SLE, where recurrence is surprisingly rare. Probably all types of glomerulonephritis recur, but there is much variation in the frequency and severity of recurrence. More studies are needed to clarify the importance of recurrence, particularly in patients with glomerulonephritis, diabetes, and the monoclonal gammopa-thies.