Kidney Transplant for C3G/IC-MPGN: What You Need to Know

If you’re declared a good candidate for transplant, you may be added to the national waiting list for a donor kidney. However, if you already have a living donor lined up, the transplant can proceed as soon as you both are ready.

• You’ll have general anesthesia, meaning that you’ll be asleep for the entire procedure.
• The surgeon places the donor kidney into your lower abdomen and attaches it to the blood vessels that lead to one of your legs.
• The tube that carries urine out of the new kidney (ureter) is attached to your bladder.
• Your own kidneys stay in place, unless they’re causing complications such as high blood pressure, kidney stones, or an infection.
• The surgery takes about three to four hours.
• Your new kidney may start making urine immediately; if not, you may need dialysis for a few days.
• You’ll spend at least several days in the hospital as you recover.

Your immune system also sees your new kidney as a foreign invader. To protect the kidney and keep your body from attacking (rejecting) it, you’ll take medications called immunosuppressants for the rest of your life or as long as you have the transplanted kidney. While these medicines will weaken your immune system, it will still function well enough to prevent you from getting serious infections.

Induction Therapy To get your body ready to accept the new kidney, you’ll have strong antirejection medicine called induction therapy administered intravenously before you receive your transplant and one or more times immediately after surgery.

Maintenance Therapy You’ll shift to maintenance therapy while you’re in the hospital, and you’ll be responsible for taking this oral medication when you get home, for as long as you have the new kidney.

Several different immunosuppressants can be prescribed, and most people will need to take a combination of medications for the best results.

“Our standard protocols include induction therapy with thymoglobulin in most patients, and then they are maintained on maintained on Prograf [tacrolimus], CellCept [mycophenolate mofetil] and prednisone,” says Stanley Jordan, MD, director of nephrology and medical director of the kidney transplant program at Cedars-Sinai Medical Center in Los Angeles. “This accounts for more than 95 percent of renal transplants in the U.S.”

• Infection due to immunosuppression
• Surgical complications such as pain, bleeding, and infection at the surgical site
• Organ rejection, which can lead to loss of the transplanted kidney

“Surgical complications like wound infections and more rarely thrombosis of the arterial or venous anastomosis are possible though the overall numbers are very small,” says Yasir A. Qazi, MD, a transplant nephrologist at Providence St. Joseph Hospital in Orange, California, and an associate professor of clinical medicine at Keck School of Medicine of USC. “With improvement in immunosuppression, the rejection rates have gone down into the teens, but with more potent immunosuppression, patients are now at higher risks of infections and cancers.”

Even with immunosuppression, organ rejection can still happen. “Rejection is more common during the first year after transplant, but modern immunosuppression is decreasing this,” says Rossana Malatesta Muncher, MD, a pediatric nephrologist at Texas Children’s and an assistant professor at Baylor College of Medicine in Houston. “Rejections can present with an acute kidney injury or be found with surveillance testing or a biopsy.”

• Hyperacute rejection happens within minutes after a transplant. It’s mainly related to incompatibility between donor and recipient, and is now rare as matching has become more accurate.
• Acute rejection can happen at any point following the transplant, although usually within days or weeks.
• Chronic rejection usually develops more than three months after transplant, but can happen years after the procedure. This type of rejection is gradual, and the signs may be hard to notice.

Acute rejection has two different causes. “Acute cellular rejection happens when immune cells directly recognize the foreign kidney and attack it,” says Dr. Malatesta Muncher. “Antibody-mediated rejection occurs when donor-specific antibodies attach to the kidney and start an immunological injury.”

A transplant only replaces the kidney — it doesn’t address the underlying cause of C3G or IC-MPGN. There’s a good chance that the immune system dysfunction that leads to these conditions will also damage the new kidney.

“Recurrent glomerular diseases are not uncommon in kidney transplant and can account for about 15 percent of kidney transplant loss long-term,” says Dr. Jordan. “C3GN/IC-MPGN are a very difficult group of diseases with poorly understood pathogenesis. However, we know that soluble factors, most likely antibodies to complement regulatory proteins, can persist in the patient’s body and reinitiate disease after transplant.”

“The new inhibitors prevent the series of reactions also known as the complement cascade, and prevent abnormal proteins from accumulating in the kidney,” says Dr. Qazi, “thus preventing inflammation and damage. The drugs are approved [by the U.S. Food and Drug Administration] for these conditions.”

Jordan is optimistic about the future for these patients. “The long-term outlook and quality of life with a transplant is excellent,” he says. “For example, the life-saving benefits of kidney transplantation are significant. Here, life expectancy is sixfold higher than patients remaining on dialysis. Anything we can do to transplant and preserve kidney function has a lifesaving benefit for the patients.”

Qazi agrees. “Kidney transplant offers a better quality of life and more years of life, compared to remaining on dialysis,” he says. “Certain conditions can recur in the kidney transplant shortening the lifespan of the transplant, but newer therapies such as the complement inhibitors can prevent this recurrence and stabilize the kidney transplant, allowing patients to enjoy a dialysis-free life.”

• A kidney transplant can improve your quality of life when you have C3G or IC-MPGN, but it doesn’t cure the underlying disease and there is a high risk of recurrence after transplantation.
• Newer medications called complement inhibitors have demonstrated promising results in clinical trials and may be effective in controlling disease recurrence.
• Regularly scheduled biopsies can detect the earliest signs of recurrence and may allow for prompt interventions.