Fibrillary GN: Cardiovascular Protection and Recurrence After Kidney Transplant

Gerald Appel, MD, opens the segment by highlighting an added benefit of nonspecific therapy in fibrillary glomerulonephritis (FGN). Beyond reducing proteinuria, agents such as ACE inhibitors, angiotensin receptor blockers, and certain antidiabetic drugs also lower cardiovascular risk, including stroke and myocardial infarction. Appel calls this a real long-term positive of the approach, because cardiovascular disease is the leading cause of death in patients with kidney dysfunction.

Appel describes how that consideration shapes drug selection in similar diseases. In younger patients with less cardiovascular concern, he may choose certain agents, while in older patients or those with diabetes, he favors drugs that also protect against future cardiovascular events.

The conversation then shifts to kidney transplantation. Appel notes that it has long been cited that about 50% of patients with FGN experience recurrence after transplant, and he asks Andrew Bomback, MD, MPH, whether that matches his experience.

Bomback says he has read the same statistics, but they do not match what he has seen. Over the past 15 years at Columbia, he can recall only one case of recurrent FGN, even as more patients with FGN have proceeded to transplant. He considers several possible explanations without endorsing any: the shift from cyclosporine to tacrolimus, from azathioprine to mycophenolate, or changes in induction therapy. Whatever the cause, he has not observed the 50% recurrence rate reported in the literature in Columbia's transplant population.

Appel agrees that recurrence has been far less common in his experience. He recalls one patient who lost a kidney donated by her husband to recurrence after about 8 years. Bomback observes that such cases stand out precisely because they are unusual. Appel adds that the true recurrence rate appears lower than historically reported and would be a worthwhile question for future study.