Filippone Edward J, Farber John L
Division of Nephrology, Department of Medicine, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA.
Department of Pathology, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA.
Clin Transplant. 2016 Nov;30(11):1394-1402. doi: 10.1111/ctr.12847. Epub 2016 Oct 13.
Membranous nephropathy (MN) may occur in a kidney transplant as recurrence of the original disease (rMN) or as a de novo MN (dnMN). rMN often occurs early, within the first year, and often in a mild or subclinical fashion. Recurrence cannot be predicted by clinical features at the time of transplantation. The natural history is increasing proteinuria over time, with less chance for spontaneous remission compared to primary MN (pMN). Antiphospholipase A2 receptor (PLA2R) antibodies should be evaluated in all patients with pMN at the time of transplantation and serially. If titers persist or rise, biopsy is indicated. Irrespective of PLA2R status, any case with proteinuria reaching 1 g/day should be biopsied. No randomized controlled trials have been published regarding treatment of rMN. Observational data support use of rituximab. Given the progressive nature of rMN and lack of spontaneous remissions, a period of observation does not seem justifiable. dnMN occurs with about equal frequency as rMN and shares features of secondary MN in native kidneys. Causes include viral infections (e.g., hepatitis B or C), which should be treated. In some cases, dnMN may represent an atypical alloimmune response. The role of rituximab in dnMN is undefined.
膜性肾病（MN）可在肾移植时作为原发病复发（rMN）或新发MN（dnMN）出现。rMN常早期发生，在第一年之内，且常呈轻度或亚临床形式。移植时的临床特征无法预测复发情况。其自然病程是蛋白尿随时间增加，与原发性MN（pMN）相比，自发缓解的机会较少。所有pMN患者在移植时及之后应连续检测抗磷脂酶A2受体（PLA2R）抗体。如果抗体滴度持续或升高，则需进行活检。无论PLA2R状态如何，任何蛋白尿达到1g/天的病例均应进行活检。关于rMN的治疗，尚无随机对照试验发表。观察性数据支持使用利妥昔单抗。鉴于rMN的进展性和缺乏自发缓解，一段时间的观察似乎不合理。dnMN的发生频率与rMN大致相同，且具有天然肾脏中继发性MN的特征。病因包括病毒感染（如乙型或丙型肝炎），应予以治疗。在某些情况下，dnMN可能代表一种非典型的同种免疫反应。利妥昔单抗在dnMN中的作用尚不清楚。
