Introduction:
Recurrence of primary focal segmental glomerulosclerosis (pFSGS) in patients after kidney transplantation is variable with increased rates of graft loss. Risk factors of recurrence include young age, steroid resistant nephrotic syndrome at presentation and higher BMI at transplant. Plasma Exchange (PLEX), Rituximab and combination of both are commonly used treatment strategies. In this study, we report the course and post transplant outcomes in patients with pFSGS as basic disease.
Methods:
In this ambispective observational study conducted at tertiary care hospital in North India, we analyzed outcomes of 36 kidney transplant recipients (n=34 retrospective) with biopsy‑proven recurrent FSGS who underwent transplant from 1990 to 2022 in our centre. Recurrence was defined as significant proteinuria (>0.5 gm/day) and a biopsy proven pFSGS.
Results:
A total of 2960 patients underwent kidney transplant from January 1990 to January 2022. 36 patients who had FSGS as native kidney disease were identified based on inclusion criteria. 11(31%) patients had biopsy proven recurrence of FSGS, 16(44%) patients had graft loss, six (16.6%) patients had acute rejections and six (16.6%) patients expired. 28 (78%) patients were males. Clinical presentation of the FSGS recurrence were nephrotic syndrome in two (18%) patients, nephrotic range proteinuria in four (36%) patients, Sub-nephrotic proteinuria in three (27%) patients, two (18%) patients had proteinuria along with graft dysfunction. Median duration for recurrence of FSGS post-transplant was 36 (IQR, 24 -72 ) months. Mean proteinuria at diagnosis was 3.7 ± 1.8 g/day. At diagnosis, mean serum creatinine was 1.57 ± 0.46 mg/dL and mean serum albumin was 3.6 ± 0.94 g/dL. Mean perioperative hospital stay was higher in the recurrence group as compared to no recurrence group (20.45±13 vs 14.9±5.90 days, p=0.08). 4 patients in no recurrence group had post operative ATN. All the patients received ACEi/ARBs, PLEX was done in two patients, one patient had partial response and other patient had progressive disease. Combined PLEX and rituximab were used in three patients with complete remission and partial remission in one and three patients respectively. Remaining six patients received only ACEi/ARBs with partial response in 3 patients. Among 11 patients who had FSGS recurrence, graft loss occurred in 6 (54.5%) patients vs 10 (40%) among patients without recurrence. The patients who had graft loss had longer median hospital stay post transplant (15.5 vs 12 days, p=0.018).Among patients with FSGS recurrence, patients with graft loss had earlier median time to recurrence 28( IQR 12 - 36) months vs 72 (IQR, 60 - 72) months, p=0.01 in patients without graft loss. Five (44.44%) patients in graft loss group had acute rejections as compared to one (5%) patient in functioning graft group (p=0.03), Patients with more than 3 HLA mismatch was higher in graft loss group (37.5% vs 31.58%,p= 0.71). Mortality rates were similar among two groups (16.67 % vs 16%, p=0.87).
Conclusions:
Recurrence of FSGS and graft loss post transplant were higher in patients with Primary FSGS. Combination of PLEX and rituximab results in better response than PLEX alone or ACEi/ARBs alone.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.