Early recurrence of focal segmental glomerulosclerosis in kidney transplant recipients: When to consider regifting

Background

Long term outcomes in transplant recipients experiencing recurrent focal segmental glomerulosclerosis (FSGS) remains poor. Despite early treatment, more than half lose their graft. The aims of this study were to evaluate treatment patterns, outcomes and to evaluate for predictors of treatment failure in recurrent FSGS.

Methods

This was a single center retrospective observational study. Between 1/2014 and 8/2019, 1860 kidney transplantations were performed at UCLA, 100 of which had end stage renal disease due to biopsy-proven FSGS. Comparative statistics were obtained and a multivariate analysis for graft outcomes in patients with recurrence was constructed. The primary outcomes were recurrent FSGS, allograft failure and pheresis dependence.

Results

Twenty-six of the 100recipients experienced FSGS recurrence. Patients with recurrence were younger (34.3 vs. 44.9, p = 0.001) and more likely to have had native nephrectomy (27% vs. 3%, p = 0.001). Gender, race, comorbidities, donor type, previous transplants and rates of rejection were similar between the recurrence and non-recurrence groups. Most patients received plasmapheresis (n = 24) with or without rituximab (11 vs. 13) which allowed for recovery of graft function in 18 patients (75%). Those experiencing a complete recovery required a median of 9 pheresis sessions, while those with graft failure (n = 3) or who became plasmapheresis-dependent (n = 5) required a median of 59 and 158 sessions, respectively. A multivariate analysis was constructed and no additional predictors of graft failure were encountered.

Conclusions

Patients with recurrent FSGS whoexperienced remissiondid so following a short course of plasmapheresis. The patients whose recurrence never resolved or who lost their graft underwent much longer courses of plasmapheresis. If this pattern of early durable response is validated in larger studies, there may be a future when transplant teams discuss the possibility of re-gifting based on treatment response to plasmapheresis following recurrence.