Primary Considerations for Patients with Chronic Kidney Disease Secondary to Granulomatosis with Polyangiitis Undergoing Kidney Transplantation

Pre-Transplantation Evaluation

Patients with granulomatosis with polyangiitis (GPA) in remission and stage 5 chronic kidney disease should be evaluated for renal transplantation, as outcomes are similar to those in patients receiving transplants for other reasons, with disease relapses in the transplanted kidney being rare, according to the American College of Rheumatology 1
Ensure the patient is in complete extrarenal remission for at least 12 months before transplantation, as recommended by the American Journal of Kidney Diseases 3
Persistent ANCA positivity should not delay kidney transplantation, as stated by the Kidney International 4, 5
Screen for potential infections including hepatitis B, hepatitis C, HIV, tuberculosis, and consider Pneumocystis jirovecii prophylaxis, as suggested by the Kidney International 5

Monitor ANCA titers, but do not change immunosuppression based on changes in ANCA titer alone, according to the American Journal of Kidney Diseases 3
Evaluate for any extrarenal manifestations of GPA that might indicate active disease, as recommended by the American College of Rheumatology 1
Consider factors that increase relapse risk: diagnosis of GPA, PR3-ANCA positivity, history of relapse, lower cyclophosphamide exposure, and glucocorticoid withdrawal, as stated by the Kidney International 5

Cyclophosphamide remains an alternative for induction treatment, especially in severe cases with serum creatinine >4 mg/dL, as suggested by the Kidney International 5
Rituximab is preferred for maintenance therapy (500 mg IV every 6 months), as recommended by the Kidney International 5
Azathioprine is an alternative maintenance agent (1-2 mg/kg/day), according to the American Journal of Kidney Diseases 6
Maintenance therapy should be continued for at least 18 months, as stated by the American Journal of Kidney Diseases and the Kidney International 5, 6

Evaluate for cardiovascular risk factors and implement appropriate preventive measures, as suggested by the Kidney International 5
Consider Pneumocystis jirovecii prophylaxis for patients receiving cyclophosphamide or rituximab, as recommended by the American College of Rheumatology 1

Increased risk of venous thrombotic events in patients with GPA, as stated by the American College of Rheumatology 1