Outcomes After Kidney Transplantation in Antineutrophil Cytoplasmic Autoantibody-Associated Renal Vasculitis.

INTRODUCTION

Antineutrophil cytoplasmic autoantibody (ANCA)-associated renal vasculitis (AAV) glomerulonephritis (GN) (AAV-GN) frequently leads to end-stage kidney disease (ESKD). Optimal management for patients with AAV-GN receiving a kidney transplantation (KT) remains poorly characterized. We compared posttransplant outcomes between patients with AAV-GN and controls in the modern era of immunosuppressive therapy.

METHODS

This multicenter retrospective study included 206 adult patients with AAV-GN and 412 matched controls who underwent KT between 2005 and 2023 in 12 French transplant centers. We compared the incidence of delayed graft function (DGF), graft failure, AAV relapses, acute rejection, and mortality between groups; and analyzed risk factors using multivariable models.

RESULTS

DGF incidence and kidney function up to 5 years after KT were similar between groups. Patients with AAV-GN showed a trend toward poorer graft survival (hazard ratio [HR] = 1.55, P = 0.077) and significantly lower overall survival (HR = 1.48, P = 0.034). AAV relapses occurred in 15 patients with AAV-GN (7.3%), significantly impacting graft survival (P = 0.008). ANCA positivity at KT tended to be associated with higher relapse risk (HR = 4.17, P = 0.065) and was associated with lower rejection risk (HR = 0.31, P = 0.016). Acute rejection incidence was comparable between groups. Azathioprine (AZA) maintenance therapy was associated with increased rejection (HR = 3.733, P = 0.012) and graft failure (HR = 3.73, P = 0.007 < 0.001). Although patients with AAV-GN were waitlisted later than controls, no specific transplant timing was associated with improved outcomes.

CONCLUSION

Although KT offers patients with AAV-GN short-term outcomes similar to controls, they face higher long-term risk of graft failure and mortality. ANCA status at transplantation may help predict immunological events, emphasizing the need for careful evaluation and monitoring, but without delaying the process. As for other nephropathies, AZA should be avoided as maintenance therapy in patients with AAV-GN. These findings highlight the need for tailored posttransplant management in patients with AAV-GN.