Subclinical rejection impairs glomerular adaptation after renal transplantation

After transplantation, glomerular volumes increases and large glomerular volume at 4 months is associated with better renal function. The aim is to characterize glomerular adaptation after the fourth month in two serial protocol biopsies and its relationship with subclinical rejection and chronic allograft nephropathy (CAN). Mean glomerular volume (Vg) was estimated according to the Weibel and Gomez method in a 4-month and 1-year serial protocol biopsies in 61 stable grafts. Glomerular enlargement (δVg) was calculated as the Vg difference between both biopsies. Banff schema was used to evaluate renal biopsies. Vg increased from 4.4±2.4 to 5.7±2.6 × 106 μm3 (P<0.001). Mean δVg was 1.0 × 106 μm3. Patients with δVg<1 were considered as patients with impaired glomerular enlargement (n=29). Impaired glomerular enlargement was associated with increased acute index score in the 4-month (1.83±1.56 vs 1.06±1.48; P<0.05) and 1-year protocol biopsies (1.52±1.59 vs 0.62±1.07; P<0.05). Impaired glomerular enlargement was also associated with increased progression of chronic lesions between the 4-month and 1-year biopsy in the glomerular (0.17±0.38 vs 0.55±0.63; P<0.01), tubular (0.38±0.56 vs 0.83±0.85; P<0.01), and interstitial compartment (0.41±0.57 vs 0.90±0.86; P<0.01). The proportion of sclerotic glomeruli between both biopsies increased in patients with impaired glomerular enlargement (1.5±3.9 to 5.3±10.1, P<0.05) while it did not modify in patients with glomerular enlargement (2.1±7.3 vs 2.6±4.5; P=NS). During the first year, glomeruli enlarge but this adaptation mechanism is impaired in patients with subclinical rejection. Moreover, impaired glomerular enlargement is associated with progression of CAN.