Clinical features and treatment of recurrent allograft nephropathy in children

doi:10.3877/cma.j.issn.1674-3903.2025.01.003

Abstract

Abstract:

Objective

To summarize the clinical and pathological features, diagnosis, and treatment of recurrent allograft nephropathy in children, and to provide experience for early diagnosis and treatment.

Methods

The clinical and pathological data of children ≤18 years old with recurrent immune glomerular disease after kidney transplantation diagnosed and treated in the First Affiliated Hospital of Sun Yat-sen University from January 2014 to October 2024 were retrospectively analyzed and summarized.

Results

There were 11 males and 7 females. Of the 18 patients, 9 cases of focal segmental glomerulosclerosis (FSGS), 5 cases of IgA nephropathy (IgAN), 2 cases of anti-neutrophil cytoplasmic antibody associated glomerulonephritis (AAGN), and 2 cases of IgA vasculitis associated glomerulonephritis (IgAVN). Among the 9 cases of FSGS, 4 cases achieved complete remission after treatment, 6 cases had normal renal function 3 months to 7 years after operation, and 5 cases had no proteinuria. Among them, 2 cases had graft failure, 1 case had graft insufficiency, and 2 cases had normal renal function. Of the 5 IgAN patients, 2 cases showed massive proteinuria and entered ESRD at 2 and 7 years after operation. Two cases of IgAVN responded to glucocorticoid therapy. One case was treated with rituximab and the symptoms disappeared. The other case experienced two relapses and maintained partial remission. Two patients with AAGN achieved complete remission with normal renal function after treatment.

Conclusions

The common recurrent allograft nephropathy in children includes FSGS, IgAN, AAGN, and IgAVN. Active renal biopsy and effective intervention can achieve good curative effects.

Key words: Kidney transplantation, Relapse, Child, Clinical feature, Therapy

Mengjie Jiang, Shujuan Huang, Yuxin Pei, Liping Rong, Yuanyuan Xu, Zhilang Lin, Yuanquan Qiu, Longshan Liu, Xiaoyun Jiang, Lizhi Chen. Clinical features and treatment of recurrent allograft nephropathy in children[J]. Chinese Journal of Transplantation(Electronic Edition), 2025, 19(01): 16-21.

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患儿	主要治疗方案	转归	术后随访时间	末次随访检测
患儿	主要治疗方案	转归	术后随访时间	尿蛋白	血清肌酐(μmol/ L)
例1	MP 冲击+血浆置换15 次(术后1 个月),福辛普利,静脉输注环孢素(术后6 个月),RTX(术后7～8 个月),输注间充质干细胞2 次,ACTH 维持治疗(术后15 个月～4 年3 个月)	治疗52 个月后尿蛋白转阴	7 年	阴性	57
例2	MP 冲击+血浆置换8 次(术后3 d～1 个月),福辛普利	治疗后2 周内尿蛋白转阴	3 个月	阴性	53
例3	MP 冲击+血浆置换15 次(术后1～2 个月),RTX(术后1～2 个月),福辛普利,ACTH 治疗(术后3～4 个月)	持续大量蛋白尿, 术后16 个月移植肾失功切除	1 年4 个月	无尿	移植肾失功
例4	MP 冲击+血浆置换10 次+ RTX(术后1～2 个月)	尿蛋白持续未转阴	8 个月	++	122
例5	首次：MP 冲击+血浆置换20 次+RTX(术后1～2 个月),输注间充质干细胞4 次再次复发：控制感染+MP 冲击+血浆置换15 次(复发后1～2 个月),RTX (复发后2 个月)	首次治疗8 个月后尿蛋白转阴术后5 年后因感染复发,治疗2 个月后尿蛋白转阴	7 年5 个月	阴性	78
例6	MP 冲击+血浆置换12 次+RTX(术后1～2 个月),福辛普利,ACTH 治疗(4 次,术后3～4 个月)	尿蛋白持续未转阴	1 年3 个月	++	57
例7	血浆置换5 次+RTX(术后1 个月),血浆置换12 次+MP冲击(术后9 个月),福辛普利	尿蛋白持续未转阴	1 年	+++	75
例8	血浆置换3 次(术后2 个月)+MP 冲击,福辛普利,RTX(术后12、29 个月各1 次)	尿蛋白持续未转阴,肾功能恶化,规律透析	3 年2 个月	+	移植肾失功
例9	调整免疫抑制维持方案(他克莫司调整为环孢素),福辛普利	尿蛋白转阴	1 年3 个月	阴性	50

患儿	主要治疗方案	转归	术后随访时间	末次随访检测
患儿	主要治疗方案	转归	术后随访时间	尿蛋白	血清肌酐(μmol/ L)
例1	MP 冲击+血浆置换15 次(术后1 个月),福辛普利,静脉输注环孢素(术后6 个月),RTX(术后7～8 个月),输注间充质干细胞2 次,ACTH 维持治疗(术后15 个月～4 年3 个月)	治疗52 个月后尿蛋白转阴	7 年	阴性	57
例2	MP 冲击+血浆置换8 次(术后3 d～1 个月),福辛普利	治疗后2 周内尿蛋白转阴	3 个月	阴性	53
例3	MP 冲击+血浆置换15 次(术后1～2 个月),RTX(术后1～2 个月),福辛普利,ACTH 治疗(术后3～4 个月)	持续大量蛋白尿, 术后16 个月移植肾失功切除	1 年4 个月	无尿	移植肾失功
例4	MP 冲击+血浆置换10 次+ RTX(术后1～2 个月)	尿蛋白持续未转阴	8 个月	++	122
例5	首次：MP 冲击+血浆置换20 次+RTX(术后1～2 个月),输注间充质干细胞4 次再次复发：控制感染+MP 冲击+血浆置换15 次(复发后1～2 个月),RTX (复发后2 个月)	首次治疗8 个月后尿蛋白转阴术后5 年后因感染复发,治疗2 个月后尿蛋白转阴	7 年5 个月	阴性	78
例6	MP 冲击+血浆置换12 次+RTX(术后1～2 个月),福辛普利,ACTH 治疗(4 次,术后3～4 个月)	尿蛋白持续未转阴	1 年3 个月	++	57
例7	血浆置换5 次+RTX(术后1 个月),血浆置换12 次+MP冲击(术后9 个月),福辛普利	尿蛋白持续未转阴	1 年	+++	75
例8	血浆置换3 次(术后2 个月)+MP 冲击,福辛普利,RTX(术后12、29 个月各1 次)	尿蛋白持续未转阴,肾功能恶化,规律透析	3 年2 个月	+	移植肾失功
例9	调整免疫抑制维持方案(他克莫司调整为环孢素),福辛普利	尿蛋白转阴	1 年3 个月	阴性	50

患儿	主要治疗方案	转归	术后随访时间	末次随访检测
患儿	主要治疗方案	转归	术后随访时间	尿蛋白	尿红细胞(个/ μL )	血清肌酐(μmol/ L)
例1	MP 冲击,福辛普利	DGF,部分缓解,肾功能恶化进展至ESRD	2 年	+++	152	移植肾失功
例2	首次复发：MP 冲击,免疫抑制剂加量,贝那普利术后5 年再次复发：MP 冲击,扁桃体切除	首次复发：尿蛋白转阴再次复发：尿蛋白不缓解,血清肌酐进行性升高,术后7 年开始腹膜透析	10 年8 个月	无尿	无尿	移植肾失功
例3	MP 冲击,福辛普利	仍有镜下血尿,未出现蛋白尿	11 个月	阴性	112	77
例4	MP 冲击+抗感染+福辛普利	仍有镜下血尿,未出现蛋白尿	1 年10 个月	阴性	148	84
例5	首次复发：MP 冲击,扁桃体切除( 术后16 个月)术后3 年再次复发：雷米普利5 mg/ d	首次复发：尿蛋白转阴,有镜下血尿再次复发：部分缓解	4 年7 个月	弱阳性	73	78

患儿	主要治疗方案	转归	术后随访时间	末次随访检测
患儿	主要治疗方案	转归	术后随访时间	尿蛋白	尿红细胞(个/ μL )	血清肌酐(μmol/ L)
例1	MP 冲击,福辛普利	DGF,部分缓解,肾功能恶化进展至ESRD	2 年	+++	152	移植肾失功
例2	首次复发：MP 冲击,免疫抑制剂加量,贝那普利术后5 年再次复发：MP 冲击,扁桃体切除	首次复发：尿蛋白转阴再次复发：尿蛋白不缓解,血清肌酐进行性升高,术后7 年开始腹膜透析	10 年8 个月	无尿	无尿	移植肾失功
例3	MP 冲击,福辛普利	仍有镜下血尿,未出现蛋白尿	11 个月	阴性	112	77
例4	MP 冲击+抗感染+福辛普利	仍有镜下血尿,未出现蛋白尿	1 年10 个月	阴性	148	84
例5	首次复发：MP 冲击,扁桃体切除( 术后16 个月)术后3 年再次复发：雷米普利5 mg/ d	首次复发：尿蛋白转阴,有镜下血尿再次复发：部分缓解	4 年7 个月	弱阳性	73	78

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