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Kidney Week

Abstract: TH-PO654

Belimumab for Recurrent Lupus Nephritis After Kidney Transplant

Session Information

Category: Glomerular Diseases

  • 1402 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Kilpatrick, Mark Duncan, Virginia Commonwealth University, Richmond, Virginia, United States
  • Gupta, Gaurav, Virginia Commonwealth University, Richmond, Virginia, United States
  • Kidd, Jason M., Virginia Commonwealth University, Richmond, Virginia, United States
Introduction

A 31-year-old woman with a history of end stage kidney disease (ESKD) due to systemic lupus erythematosus (SLE) glomerulonephritis (Class IV/V) underwent deceased donor pediatric en bloc kidney transplant. Nine months after transplant, she developed proteinuria with 2.2 g/g on a spot urine protein to creatinine ratio. Serum creatinine was stable at 1.3 mg/dl and she was maintained on tacrolimus 4 mg twice daily, mycophenolate mofetil 360 mg twice daily and prednisone 5 mg daily. She had no prior history of rejection.

Case Description

Renal biopsy was performed and showed focal, active nephritis with mesangial hypercellularity and inflammatory cells in the endocapillary space, consistent with class III+V lupus nephritis with an activity score of 3/24. Given the recurrence of SLE nephritis despite treatment with immunosuppression, treatment with belimumab was initiated at 200 mcg weekly given subcutaneously. Six months after starting treatment, proteinuria had decreased to 0.2 g/g with stable kidney function. Repeat kidney biopsy revealed class II and class V lupus nephritis with improvement in activity index to 0/24.

Discussion

Recurrence of SLE nephritis after transplant has been shown to increase the risk of graft loss1. Management of recurrence varies by provider but can involve steroids and alteration of the immunosuppressive regimen2. Belimumab is a fully human IgG1λ recombinant monoclonal antibody directed against B-lymphocyte Stimulator (BlyS) that binds to endogenous B-cell activating factor, leading to B-cell apoptosis and diminished autoantibody production. Use has been shown to reduce disease activity and flares in patients with SLE3. When added to standard therapy for lupus nephritis, belimumab has been shown to improve the chances of a renal response4. The addition of belimumab should be considered in patients with recurrent lupus nephritis after kidney transplant.

1 Contreras G, et al. Recurrence of lupus nephritis after kidney transplantation. J Am Soc Neph. 2010 Jul;21(7):1200-7.
2 Chadban SJ. Glomerulonephritis recurrence in the renal graft. J Am Soc Neph. 2001 Feb;12(2):394-402.
3 Furie R, et al; BLISS-76 Study Group. A phase III, randomized, placebo-controlled study of belimumab. Arthritis Rheum. 2011 Dec;63(12):3918-30.
4 Furie R, et al. Two-Year, Randomized, Controlled Trial of Belimumab in Lupus Nephritis. N Engl J Med. 2020 Sep 17;383(12):1117-1128.