Recurrent, Nonrecurrent, and De Novo Membranous Nephropathy After Kidney Transplantation: A Systematic Review and Meta-Analysis

Thanyarat Phumthian; Veerapat Wattanasatja; Aschariya Wipattanakitcharoen; Thunyatorn Wuttiputhanun; Asada Leelahavanichkul; Natavudh Townamchai; Yingyos Avihingsanon; Suwasin Udomkarnjananun

doi:10.1016/j.xkme.2026.101284

Recurrent, Nonrecurrent, and De Novo Membranous Nephropathy After Kidney Transplantation: A Systematic Review and Meta-Analysis

Kidney Med. 2026 Feb 6;8(4):101284. doi: 10.1016/j.xkme.2026.101284. eCollection 2026 Apr.

Authors

Thanyarat Phumthian^{1

2}, Veerapat Wattanasatja^{1

3}, Aschariya Wipattanakitcharoen¹, Thunyatorn Wuttiputhanun^{1

4}, Asada Leelahavanichkul^{5

6}, Natavudh Townamchai^{1

4

7}, Yingyos Avihingsanon^{1

4

7}, Suwasin Udomkarnjananun^{1

4

5

7}

Affiliations

¹ Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand.
² Department of Internal Medicine, Ubon Ratchathani University Hospital and College of Medicine and Public Health, Ubon Ratchathani University, Ubon Ratchathani, Thailand.
³ Department of Internal Medicine, Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand.
⁴ Excellence Center for Organ Transplantation (ECOT), King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand.
⁵ Center of Excellence on Translational Research in Inflammation and Immunology (CETRII), Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
⁶ Immunology Unit, Department of Microbiology, Chulalongkorn University, Bangkok, Thailand.
⁷ Renal Immunology and Renal Transplant Center of Excellence, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Abstract

Rationale & objective: Recurrent and de novo membranous nephropathy (MN) are significant complications after kidney transplantation, yet prevalence, risk determinants, and treatment outcomes have not been comprehensively quantified.

Study design: Systematic review and meta-analysis.

Setting & participants: Kidney transplant recipients with native-kidney MN (recurrent or nonrecurrent) and recipients with de novo MN.

Selection criteria for studies: PubMed, Scopus, and the Cochrane Library were searched through June 30, 2025; studies comparing risk factors and outcomes among these groups were eligible for meta-analyses.

Data extraction: Study characteristics, demographics, transplant features, outcomes including remission and allograft loss.

Analytic approach: Random-effects meta-analyses calculated weighted mean differences or pooled ORs for comparisons between recurrent versus nonrecurrent or de novo MN, allograft outcomes, and response to rituximab.

Results: The included studies comprised a total of 2,259 kidney transplant recipients with recurrent (28%), nonrecurrent (61%), or de novo MN (11%). Recurrence prevalence was 39% (95% CI, 28%-50%) in studies with protocol biopsies versus 25% (95% CI, 20%-29%) without protocol biopsies (P = 0.046). Compared with nonrecurrence, recurrent MN was linked to older recipient age, shorter dialysis vintage and interval from native MN to dialysis, living-donor grafts, and higher pretransplant antiphospholipase A2 receptor antibody titer. Mycophenolic acid and prednisolone use was protective against recurrent MN. De novo MN carried a higher associated rejection than recurrent MN (OR, 2.30; 95% CI, 1.16-4.58). Rituximab increased remission odds (OR, 4.90; 95% CI, 1.70-14.13). Meta-regression demonstrated a significant decline in allograft loss rates over time following MN recurrence.

Limitations: Substantial heterogeneity and small-study effects in some variables; magnitudes should be interpreted cautiously.

Conclusions: MN recurs in approximately one-third of recipients. Protocol biopsy should be utilized in recipients with history of native MN. Rituximab emerges as the preferred first-line treatment for recurrent MN.

Keywords: Kidney transplantation; membranous nephropathy; meta-analysis; prevalence; recurrent glomerular disease; risk factors; systematic review; treatment.

Plain language summary

Recurrent glomerular disease after kidney transplantation is a challenging posttransplant complication, and recurrent membranous nephropathy (MN) is among the most common entities. Prior evidence has established pretransplant antiphospholipase A2 receptor antibodies as a risk factor for recurrence; however, other risk factors and treatment outcomes have not been comprehensively assessed. This study is the first to include all available evidence on posttransplant MN and shows that protocol biopsy increases detection of recurrent MN and is associated with a lower risk of allograft loss. In addition to identifying several risk factors for recurrence, the analysis demonstrates that rituximab therapy yields a significantly higher remission rate than non-rituximab treatment in recurrent MN.