Recurrent, Nonrecurrent, and De Novo Membranous Nephropathy After Kidney Transplantation: A Systematic Review and Meta-Analysis.

RATIONALE &

OBJECTIVE

Recurrent and de novo membranous nephropathy (MN) are significant complications after kidney transplantation, yet prevalence, risk determinants, and treatment outcomes have not been comprehensively quantified.

STUDY

DESIGN

Systematic review and meta-analysis.

SETTING &

PARTICIPANTS

Kidney transplant recipients with native-kidney MN (recurrent or nonrecurrent) and recipients with de novo MN.

SELECTION CRITERIA FOR STUDIES: PubMed, Scopus, and the Cochrane Library were searched through June 30, 2025; studies comparing risk factors and outcomes among these groups were eligible for meta-analyses.

DATA EXTRACTION: Study characteristics, demographics, transplant features, outcomes including remission and allograft loss.

ANALYTIC APPROACH: Random-effects meta-analyses calculated weighted mean differences or pooled ORs for comparisons between recurrent versus nonrecurrent or de novo MN, allograft outcomes, and response to rituximab.

RESULTS

The included studies comprised a total of 2,259 kidney transplant recipients with recurrent (28%), nonrecurrent (61%), or de novo MN (11%). Recurrence prevalence was 39% (95% CI, 28%-50%) in studies with protocol biopsies versus 25% (95% CI, 20%-29%) without protocol biopsies (P = 0.046). Compared with nonrecurrence, recurrent MN was linked to older recipient age, shorter dialysis vintage and interval from native MN to dialysis, living-donor grafts, and higher pretransplant antiphospholipase A2 receptor antibody titer. Mycophenolic acid and prednisolone use was protective against recurrent MN. De novo MN carried a higher associated rejection than recurrent MN (OR, 2.30; 95% CI, 1.16-4.58). Rituximab increased remission odds (OR, 4.90; 95% CI, 1.70-14.13). Meta-regression demonstrated a significant decline in allograft loss rates over time following MN recurrence.

LIMITATIONS: Substantial heterogeneity and small-study effects in some variables; magnitudes should be interpreted cautiously.

CONCLUSIONS

MN recurs in approximately one-third of recipients. Protocol biopsy should be utilized in recipients with history of native MN. Rituximab emerges as the preferred first-line treatment for recurrent MN.