Late-onset recurrent lupus nephritis in a kidney transplant recipient

Long-term kidney allograft survival continues to be a challenge, despite improvements in the short term. Recurrence of glomerular disease is a significant cause of allograft failure. We report a case of graft dysfunction 27 years post transplant attributed to biopsy-proven recurrent class IV lupus nephritis. Following targeted medication adjustments aimed at treating lupus nephritis, the patient achieved complete remission within 6 months, which has been sustained for 4 years. Although recurrent lupus nephritis is reported to occur up to 16 years after transplantation, it is uncommon, and represents a potentially treatable cause of graft failure. This report underscores the critical need for heightened awareness and prompt management of recurrent lupus nephritis regardless of the time post transplant to enhance long-term allograft survival. Furthermore, our case highlights that positive allograft staining in peritubular capillaries for C4d may result from recurrent immune-complex disease as opposed to antibody-mediated rejection.