Long-term outcomes and recurrence in kidney transplant recipients with membranoproliferative glomerulonephritis – a nationwide cohort study

Membranoproliferative glomerulonephritis (MPGN) is rare but often aggressive, with most patients progressing to end-stage kidney disease (ESKD). Recurrence after kidney transplantation is frequent and strongly associated with graft loss. Data on long-term outcomes after transplantation are needed. We conducted a nationwide retrospective cohort study including all patients in Norway with biopsy-confirmed membranoproliferative patterns of glomerular injury between 1991 and 2012, who received at least one kidney transplant before May 2024. Clinical, histopathological, and transplant data were retrieved from national registries and patient records. Primary endpoints were MPGN recurrence and graft loss due to recurrence. Forty-four patients were included. The median follow-up duration from the time of native kidney biopsy to the last follow-up was 17.3 years (2.3–36.1 years), while the median time from first kidney transplantation to last follow-up was 9.0 years (0.9–32.5 years). Recurrence in the first graft occurred in 18 patients at a median time of 20 months (2–76 months). Among those with recurrence, 11 of 18 lost the graft during follow-up compared to six of 26 without recurrence. Fine-Gray competing risk analysis confirmed recurrence as a strong predictor of graft loss. Earlier recurrence markedly increased cumulative graft failure (Subdistribution Hazard Ratio = 0.78 per log-day, 95% CI 0.65–0.95, p = 0.01). The median time from first transplantation to graft failure in the recurrence group was 48 months (10–97 months). A large proportion of patients (31/44) had no identifiable underlying disease and were classified as idiopathic. Among those who underwent retransplantation, recurrence and subsequent graft loss remained common, and most of these cases were idiopathic. Recurrence of MPGN after kidney transplantation is common and strongly associated with graft loss. Taken together, these findings highlight MPGN recurrence as a major determinant of long-term graft survival and emphasize the need for improved disease characterization, particularly in patients with idiopathic disease.