Early recurrence of ANCA-associated vasculitis within one month of kidney transplantation

Recurrence of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) after kidney transplantation is relatively uncommon due to modern immunosuppressive regimens, with early recurrence being particularly rare. We present the case of a 70-year-old woman with end-stage kidney disease of uncertain etiology who developed a biopsy-proven recurrence of pauci-immune crescentic glomerulonephritis within 1 month of receiving a deceased donor kidney transplant. Her initial allograft function was excellent but was followed by a rapid rise in serum creatinine, microscopic hematuria, and proteinuria by post-operative day 20. Serology confirmed a high p-ANCA titer. She was treated with pulse steroids and rituximab, with subsequent stabilization of her kidney function. This case highlights that AAV can recur very early in the post-transplant period and underscores the critical need to maintain a high index of suspicion for recurrent or de novo pauci-immune glomerulonephritis in transplant recipients with early allograft dysfunction, especially when the cause of their native kidney disease is unclear.