Preemptive plasmapheresis and recurrence of focal segmental glomerulosclerosis in pediatric renal transplantation

Abstract

FSGS has a high recurrence rate after renal transplantation. To examine the effects of the use of preemptive and post-transplant PP on recurrence and graft outcome, we conducted a retrospective study on 34 pediatric patients (mean age 13±5 yr) with biopsy-proven pretransplant FSGS and who underwent a renal transplantation between 1996 and 2007. Recurrence was defined as a serum albumin level of <3.0g/L in the presence of nephrotic-range proteinuria (>40mg/m(2) /h). Total response to PP therapy was defined as the resolution of the nephrotic-range proteinuria and partial response as persistent proteinuria despite PP but not in the nephrotic range. Fifteen patients received a LD renal transplantation and 19 patients received a DD renal transplantation. Nineteen patients received CsA and 14 patients received tacrolimus. Nineteen patients (56%) had FSGS recurrence. There was no difference in the recurrence rate between patients receiving CsA vs. tacrolimus. Among the 15 LD patients, 13 received preemptive PP (1-10 sessions) and seven patients (47%) had subsequent FSGS recurrence. Among the 19 DD patients, four received preemptive PP and 12 (63%) had FSGS recurrence. The number of preemptive PP did not affect the recurrence rate. In a group of patients with a previous graft loss secondary to recurrence, the rate of recurrence was lower than expected (40%) and two of the three patients who did not recur had three or more sessions of preemptive PP. Of the 19 patients with recurrence, 17 were treated with PP therapy and 88% of the patients fully or partially responded. Only five patients had graft loss at three yr post-transplant: two from FSGS recurrence and three from non-compliance. These results suggest that preemptive PP does not decrease the rate of recurrence after transplantation but might be beneficial in treating high-risk patients with documented recurrence. Patients with FSGS recurrence post-transplant can achieve good graft survival with both LD and DD transplantation.

Recurrent focal segmental glomerulosclerosis after kidney transplantation

“…Plasmapheresis Plasma-based treatments, primarily plasmapheresis, have been used as a first-line treatment for FSGS and for recurrent FSGS after transplantation for nearly 20 years [5,[46][47][48][49][50][51][52][53][54][55][56][57][58][59]. The results of select studies performed since the year 2000 with larger numbers of patients are summarized in Table 2.…”

Therapeutic plasma exchange for the treatment of pediatric renal diseases in 2013

“…However, recurrence is still unpredictable, making identification of those who would benefit from prophylactic TPE difficult [48,54,55]. Prophylactic TPE would likely be most beneficial in patients with a history of recurrent FSGS in a previous transplant [56] or in those with an identified glomerular permeability factor [54,57].…”

Plasmapheresis in Immunologic Renal Disease

“…Perhaps as a result of this, the use of TPE in primary FSGS has produced variable results and cannot be generally recommended. However, in patients with recurrent FSGS following renal transplantation, TPE is frequently reported to be of benefit [20,21,22]. We therefore recommend TPE in patients with rapid onset of proteinuria following renal transplantation.…”