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Hansrivijit P, Ghahramani N. Combined rituximab and plasmapheresis or plasma exchange for focal segmental glomerulosclerosis in adult kidney transplant recipients: a meta-analysis. Int Urol Nephrol 2020; 52:1377-1387. [DOI: 10.1007/s11255-020-02462-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/31/2020] [Indexed: 12/21/2022]
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2
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Kaur P, Singh B, Patel P, Vasudev R, Rampal U, Shamoon F. Non-ischemic cardiomyopathy with focal segmental glomerulosclerosis. J Community Hosp Intern Med Perspect 2020; 10:154-157. [PMID: 32850054 PMCID: PMC7425630 DOI: 10.1080/20009666.2020.1742470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome,
accounting for 40% of nephrotic syndrome in adults. FSGS has diverse clinical and
morphological features and underlying pathogenesis. We present a case of a 33-year-old
male presenting with acute systolic heart failure complicated with left ventricular
thrombus with embolism to coronary circulation and bilateral deep vein thrombosis. He
was found to have nephrotic range proteinuria with kidney biopsy showing FSGS.
Association of FSGS with cardiomyopathy has been reported in children. However, in
adults, according to our best knowledge, there have not been any report of FSGS and
non-ischemic cardiomyopathy or it is at least underreported. Abbreviations FSGS: Focal segmental glomerulosclerosis; ESRD: End-stage renal disease; NOS: Not
otherwise specified; LV: Left ventricle
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Affiliation(s)
- Parminder Kaur
- Saint Joseph’s University Medical Center, Paterson, NJ, 07013, USA
| | - Balraj Singh
- Saint Joseph’s University Medical Center, Paterson, NJ, 07013, USA
| | - Prem Patel
- Saint Joseph’s University Medical Center, Paterson, NJ, 07013, USA
| | - Rahul Vasudev
- Saint Joseph’s University Medical Center, Paterson, NJ, 07013, USA
| | - Upamanyu Rampal
- Saint Joseph’s University Medical Center, Paterson, NJ, 07013, USA
| | - Fayez Shamoon
- Saint Joseph’s University Medical Center, Paterson, NJ, 07013, USA
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3
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Mansur JB, Sandes-Freitas TV, Kirsztajn GM, Cristelli MP, Mata GF, de Paula MI, Grenzi PC, Martins SBS, Felipe CR, Tedesco-Silva H, Pestana JOM. Clinical features and outcomes of kidney transplant recipients with focal segmental glomerulosclerosis recurrence. Nephrology (Carlton) 2019; 24:1179-1188. [PMID: 30891898 DOI: 10.1111/nep.13589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 11/29/2022]
Abstract
AIM Focal segmental glomerulosclerosis recurs in up to 30% and up to 80% of adult and pediatric kidney transplant recipients, respectively. There is no standard of care treatment. The purpose of this study was to evaluate clinical characteristics, treatments and outcomes of patients with focal segmental glomerulosclerosis recurrence (FSGSr). METHODS This was a retrospective single-center cohort study including FSGSr patients treated with plasmapheresis (PP) and combinations of high dose steroids, cyclosporine and rituximab. RESULTS Among 61 patients included in this analysis the median time to diagnosis was 19 days. The incidence of first biopsy-confirmed FSGSr was 18% reaching 52.4% with follow-up biopsies. During PP treatment 54% of the patients developed infectious complications. PP was discontinued in 37% of patients due to treatment failure (no remission or graft loss) and in 26% due to an adverse event. All patients who discontinued PP due to adverse event did not show clinical response or lost the allograft. The incidence of acute rejection was 34.4%. The incidences of partial and complete remissions were 16.4% and 27.8%, respectively. Overall 6-years patient and graft survivals were 90.7% and 64.5%, respectively. CONCLUSION This analysis confirms the low, variable and unpredictable rate of FSGSr remission, inconsistencies among available therapeutic options and its high rate of adverse events, and the negative impact on graft survival.
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Affiliation(s)
- Juliana B Mansur
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Gianna M Kirsztajn
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Marina P Cristelli
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Gustavo F Mata
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Mayara I de Paula
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Patricia C Grenzi
- Microbiology and Immunology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Suelen B S Martins
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Claudia R Felipe
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Hélio Tedesco-Silva
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - José O M Pestana
- Nephrology Division, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
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Rituximab and Therapeutic Plasma Exchange in Recurrent Focal Segmental Glomerulosclerosis Postkidney Transplantation. Transplantation 2018; 102:e115-e120. [PMID: 29189487 DOI: 10.1097/tp.0000000000002008] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Focal segmental glomerulosclerosis (FSGS) is a common cause of end-stage renal disease with a high rate of recurrence after kidney transplantation. Several factors, such as white race, rapid progression, and previous allograft failure due to recurrence, were found to be risks of recurrence. Data are limited on the benefits of rituximab and/or therapeutic plasma exchange (TPE) in preventing recurrence. In this study, we sought to assess the efficacy of rituximab and TPE for the prevention and treatment of recurrent FSGS after kidney transplantation. METHODS We enrolled 66 patients with FSGS in this prospective observational study and followed their outcomes. Patients with high risk for recurrence received preventative therapy with TPE and/or rituximab. RESULTS Twenty-three (62%) of the 37 patients who received preventative therapy developed recurrence compared with 14 (51%) recurrences of the 27 patients who did not receive any therapy (P = 0.21). There was a trend for less relapse when rituximab was used as a therapy for recurrent FSGS (6/22 vs 9/18, P = 0.066). We used a clinical score of 5 values to assess the prediction of FSGS recurrence. A score of 3 or more had a predictive receiver operating characteristic curve of 0.72. Treatment with TPE and/or rituximab resulted in better allograft survival than historical studies. Allograft failure because of recurrent FSGS occurred in only 6 (9%) patients. CONCLUSIONS Preventative therapies do not decrease the recurrence rate of recurrent FSGS. However, prompt treatment of recurrence with these therapies may result in improved outcomes.
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5
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Idiopathic Nephrotic Syndrome: Characteristics and Identification of Prognostic Factors. J Clin Med 2018; 7:jcm7090265. [PMID: 30205613 PMCID: PMC6162818 DOI: 10.3390/jcm7090265] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/03/2018] [Accepted: 09/07/2018] [Indexed: 12/12/2022] Open
Abstract
There are various histopathological forms of idiopathic nephrotic syndrome, including minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS). Whereas some relapse predictor factors have been identified in renal transplantation, the clinical future of idiopathic nephrotic syndrome in the native kidney remains uncertain. We designed a multicentric retrospective descriptive cohort study including all patients aged 15 years and over whose renal biopsy confirmed MCD or FSGS between January 2007 and December 2014. We studied 165 patients with idiopathic nephrotic syndrome; 97 with MCD and 68 with FSGS. In the MCD cohort, 91.7% of patients were treated with corticosteroids for a median total duration of 13 months. During 45 months of follow-up, 92.8% of patients achieved remission and 45.5% experienced relapse. In this cohort, 5% of patients experienced terminal kidney disease. With respect to FSGS patients, 51.5% were treated with corticosteroids for a median total duration of 15 months. During 66 months of follow-up, 73.5% of patients achieved remission and 20% experienced relapse. In this cohort, 26.5% of patients experienced terminal kidney disease. No statistical association was observed between clinical and biological initial presentation and relapse occurrence. This study describes the characteristics of a cohort of patients with the nephrotic idiopathic syndromes of MCD and FSGS from the time of renal biopsy and throughout follow-up.
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6
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Dumas De La Roque C, Combe C, Rigothier C. [Up to date of pathophysiology mechanism of idiopathic nephrotic syndromes: Minimal change disease and focal and segmental glomerulosclerosis]. Nephrol Ther 2018; 14:501-506. [PMID: 30150079 DOI: 10.1016/j.nephro.2018.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/03/2018] [Indexed: 01/27/2023]
Abstract
Idiopathic nephrotic syndrome represents up to 30% of adult glomerulopathies. However, its prognosis according to remission, relapse and renal failure remains unchanged since the 80s and prediction remains difficult. Physiopathology of adult idiopathic nephrotic syndrome is complex and multifactorial, including immunologic and environmental factors and a putative permeability-circulating factor, still unknown. In this point of view, we propose to summarize actual knowledge about idiopathic minimal change disease and focal and segmental glomerulosclerosis physiopathology.
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Affiliation(s)
- Charlotte Dumas De La Roque
- Service de néphrologie transplantation et dialyse, centre hospitalier universitaire de Bordeaux, 33076 Bordeaux, France.
| | - Christian Combe
- Service de néphrologie transplantation et dialyse, centre hospitalier universitaire de Bordeaux, 33076 Bordeaux, France; Inserm U1026, université de Bordeaux, 33076 Bordeaux, France
| | - Claire Rigothier
- Service de néphrologie transplantation et dialyse, centre hospitalier universitaire de Bordeaux, 33076 Bordeaux, France; Inserm U1026, université de Bordeaux, 33076 Bordeaux, France
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7
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Bansal SB, Sethi SK, Jha P, Duggal R, Kher V. Remission of post-transplant focal segmental glomerulosclerosis with angiotensin receptor blockers. Indian J Nephrol 2017; 27:154-156. [PMID: 28356673 PMCID: PMC5358161 DOI: 10.4103/0971-4065.183600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Recurrence of focal segmental glomerulosclerosis (FSGS) is common after kidney transplantation. Plasmapheresis (PP) is considered to be the most effective treatment; however, results are variable and relapse is common after stopping plasmapheresis. Here, we report an unusual case of recurrent FSGS, who achieved complete remission with angiotensin receptor blocker therapy.
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Affiliation(s)
- S B Bansal
- Department of Nephrology and Kidney Transplantation, Medanta Kidney and Urology Institute, Medanta Medicity, Gurgaon, Haryana, India
| | - S K Sethi
- Department of Nephrology and Kidney Transplantation, Medanta Kidney and Urology Institute, Medanta Medicity, Gurgaon, Haryana, India
| | - P Jha
- Department of Nephrology and Kidney Transplantation, Medanta Kidney and Urology Institute, Medanta Medicity, Gurgaon, Haryana, India
| | - R Duggal
- Department of Pathology, Medanta Kidney and Urology Institute, Medanta Medicity, Gurgaon, Haryana, India
| | - V Kher
- Department of Nephrology and Kidney Transplantation, Medanta Kidney and Urology Institute, Medanta Medicity, Gurgaon, Haryana, India
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Clark WF, Huang SHS, Walsh MW, Farah M, Hildebrand AM, Sontrop JM. Plasmapheresis for the treatment of kidney diseases. Kidney Int 2016; 90:974-984. [DOI: 10.1016/j.kint.2016.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 01/24/2023]
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9
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Kashgary A, Sontrop JM, Li L, Al-Jaishi AA, Habibullah ZN, Alsolaimani R, Clark WF. The role of plasma exchange in treating post-transplant focal segmental glomerulosclerosis: A systematic review and meta-analysis of 77 case-reports and case-series. BMC Nephrol 2016; 17:104. [PMID: 27473582 PMCID: PMC4966699 DOI: 10.1186/s12882-016-0322-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 07/21/2016] [Indexed: 12/11/2022] Open
Abstract
Background Evidence on the role of plasma exchange for treating recurrent post-transplant focal segmental glomerulosclerosis (FSGS) comes largely from individual cases and uncontrolled series. We conducted a systematic review and meta-analysis to estimate the remission rate after treatment with plasma exchange, and to determine if remission varied with patient or treatment characteristics. Methods We searched MEDLINE, EMBASE, Science Citation Index Expanded, and the Conference Proceedings Citation Index (Science and BIOSIS) for studies of patients with post-transplant recurrent FSGS who were treated with plasma exchange after recurrence (1950–2012). Of 678 studies screened, 77 met our inclusion criteria: 34 case reports (45 patients) and 43 case series (378 patients). We extracted patient-level data from each study and used random-effects models to calculate remission, defined as proteinuria <3.5 g/day (partial) or <0.5 g/day (complete). Results The overall remission rate in 423 patients with outcome data was 71 % (95 % CI: 66 % to 75 %). In 235 patients with data on age, remission was similar for adults and children: 69.1 % (95 % CI: 59.6 % to 77.2 %) and 70.2 % (95 % CI: 61.1 % to 77.9 %). Males were more likely to achieve remission (OR = 2.85; 95 % CI: 1.44 to 5.62) and patients treated within 2 weeks of recurrence showed a trend towards higher likelihood of remission (OR = 2.16; 95 % CI: 0.93 to 5.01). Proteinuria >7 g/day at recurrence was inversely associated with remission (OR = 0.43; 95 % CI: 0.19 to 0.97). Age and type of kidney transplant (living vs. deceased) did not associate with remission. Conclusion In this systematic review of patients with recurrent post-transplant FSGS, 71 % of patients achieved full or partial remission after treatment with plasma exchange; however, extensive missing data and lack of a control group limit any conclusions on causality. Electronic supplementary material The online version of this article (doi:10.1186/s12882-016-0322-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Abdullah Kashgary
- Division of Nephrology, Department of Medicine, Western University, London, Canada.,Department of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.,Victoria Hospital, 800 Commissioners Road East, A2-343, London, ON, Canada, N6A 5W9
| | - Jessica M Sontrop
- Department of Epidemiology and Biostatistics, Western University, London, Canada.,Kidney Clinical Research Unit, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada, N6A 5A5.,Victoria Hospital, 800 Commissioners Road East, A2-343, London, ON, Canada, N6A 5W9
| | - Lihua Li
- Kidney Clinical Research Unit, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada, N6A 5A5.,Victoria Hospital, 800 Commissioners Road East, A2-343, London, ON, Canada, N6A 5W9
| | - Ahmed A Al-Jaishi
- Kidney Clinical Research Unit, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada, N6A 5A5.,Victoria Hospital, 800 Commissioners Road East, A2-343, London, ON, Canada, N6A 5W9
| | - Zainab N Habibullah
- Division of Nephrology, Department of Medicine, Western University, London, Canada.,Victoria Hospital, 800 Commissioners Road East, A2-343, London, ON, Canada, N6A 5W9
| | - Roaa Alsolaimani
- Division of Nephrology, Department of Medicine, Western University, London, Canada.,Department of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - William F Clark
- Division of Nephrology, Department of Medicine, Western University, London, Canada. .,Kidney Clinical Research Unit, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada, N6A 5A5. .,Victoria Hospital, 800 Commissioners Road East, A2-343, London, ON, Canada, N6A 5W9.
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Ogata H, Akizawa T, Kinugasa E. What are the Newer Applications for Therapeutic Apheresis in Nephrology?: Clinical Application of Therapeutic Apheresis in Nephrology in Japan. Semin Dial 2016; 29:359-65. [PMID: 27461967 DOI: 10.1111/sdi.12525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hiroaki Ogata
- Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan.
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Eriko Kinugasa
- Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
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Circulating Permeability Factors in Primary Focal Segmental Glomerulosclerosis: A Review of Proposed Candidates. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3765608. [PMID: 27200372 PMCID: PMC4856884 DOI: 10.1155/2016/3765608] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/22/2016] [Indexed: 12/20/2022]
Abstract
Primary focal segmental glomerulosclerosis (FSGS) is a major cause of the nephrotic syndrome and often leads to end-stage renal disease. This review focuses on circulating permeability factors in primary FSGS that have been implicated in the pathogenesis for a long time, partly due to the potential recurrence in renal allografts within hours after transplantation. Recently, three molecules have been proposed as a potential permeability factor by different groups: the soluble urokinase plasminogen activator receptor (suPAR), cardiotrophin-like cytokine factor-1 (CLCF-1), and CD40 antibodies. Both CLCF-1 and CD40 antibodies have not been validated by independent research groups yet. Since the identification of suPAR, different studies have questioned the validity of suPAR as a biomarker to distinguish primary FSGS from other proteinuric kidney diseases as well as suPAR's pathogenic role in podocyte damage. Researchers have suggested that cleaved molecules of suPAR have a pathogenic role in FSGS but further studies are needed to determine this role. In future studies, proposed standards for the research of the permeability factor should be carefully followed. The identification of the permeability factor in primary FSGS would be of great clinical relevance as it could influence potential individual treatment regimen.
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12
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Plasma Exchange for the Recurrence of Primary Focal Segmental Glomerulosclerosis in Adult Renal Transplant Recipients: A Meta-Analysis. J Transplant 2015; 2015:639628. [PMID: 26697207 PMCID: PMC4677212 DOI: 10.1155/2015/639628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 11/16/2015] [Indexed: 01/10/2023] Open
Abstract
Background. Posttransplant recurrence of primary focal segmental glomerulosclerosis (rFSGS) in the form of massive proteinuria is not uncommon and has detrimental consequences on renal allograft survival. A putative circulating permeability factor has been implicated in the pathogenesis leading to widespread use of plasma exchange (PLEX). We reviewed published studies to assess the role of PLEX on treatment of rFSGS in adults. Methods. Eligible manuscripts compared PLEX or variants with conventional care for inducing proteinuria remission (PR) in rFSGS and were identified through MEDLINE and reference lists. Data were abstracted in parallel by two reviewers. Results. We detected 6 nonrandomized studies with 117 cases enrolled. In a random effects model, the pooled risk ratio for the composite endpoint of partial or complete PR was 0,38 in favour of PLEX (95% CI: 0,23–0,61). No statistical heterogeneity was observed among included studies (I2 = 0%, p = 0,42). On average, 9–26 PLEX sessions were performed to achieve PR. Renal allograft loss due to recurrence was lower (range: 0%–67%) in patients treated with PLEX. Conclusion. Notwithstanding the inherent limitations of small, observational trials, PLEX appears to be effective for PR in rFSGS. Additional research is needed to further elucidate its optimal use and impact on long-term allograft survival.
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Wada T, Nangaku M. A circulating permeability factor in focal segmental glomerulosclerosis: the hunt continues. Clin Kidney J 2015; 8:708-15. [PMID: 26613029 PMCID: PMC4655796 DOI: 10.1093/ckj/sfv090] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 08/11/2015] [Indexed: 01/23/2023] Open
Abstract
Primary focal segmental glomerulosclerosis (FSGS) is one of the major causes of steroid-resistant nephrotic syndrome, and renal prognosis in patients with steroid-resistant FSGS is poor. It has been long speculated that a circulating permeability factor should be implicated in the pathogenesis of the disease because a substantial portion of the patients with primary FSGS experience recurrence shortly after transplantation. Although molecules such as cardiotrophin-like cytokine 1 (CLC-1) and anti-CD40 antibody have been proposed to be potential circulating permeability factors, a definitive factor remains to be discovered. Soluble urokinase-type plasminogen activator receptor (suPAR) has attracted substantial attention and garnered scrutiny by renal researchers since Reiser's group suggested that it was linked to the pathogenesis of primary FSGS and that it might be useful as a diagnostic biomarker. A number of different cohort studies have shown that serum suPAR levels are negatively associated with renal function and can scarcely differentiate FSGS from the other glomerular/renal diseases. In contrast to initial studies, several in vivo studies investigating the effects of forced suPAR upregulation could not show the induction of proteinuria or podocyte injury. Currently it is suggested that a different form of suPAR, which cannot be measured by presently available enzyme-linked immunosorbent assay, might be the culprit; however, it remains to be determined whether this is the case. Because a circulating permeability factor might be a useful biomarker for diagnosing FSGS as well as a potent therapeutic target for primary and recurrent FSGS, further dedicated work will be needed.
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Affiliation(s)
- Takehiko Wada
- Division of Nephrology and Endocrinology , University of Tokyo School of Medicine , Tokyo 113-8655 , Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology , University of Tokyo School of Medicine , Tokyo 113-8655 , Japan
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14
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Keith DS. Therapeutic apheresis in renal transplantation; current practices. J Clin Apher 2014; 29:206-10. [DOI: 10.1002/jca.21330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/01/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Douglas S. Keith
- Division of Nephrology; University of Virginia Medical Center; Charlottesville Virginia
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15
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Hildebrand AM, Huang SHS, Clark WF. Plasma exchange for kidney disease: what is the best evidence? Adv Chronic Kidney Dis 2014; 21:217-27. [PMID: 24602471 DOI: 10.1053/j.ackd.2014.01.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/14/2014] [Accepted: 01/15/2014] [Indexed: 11/11/2022]
Abstract
Therapeutic plasma exchange (TPE) has been used as adjunctive therapy for various kidney diseases dating back to the 1970s. In many cases, support for TPE was on mechanistic grounds given the potential to remove unwanted large molecular-weight substances such as autoantibodies, immune complexes, myeloma light chains, and cryoglobulins. More recently, growing evidence from randomized controlled trials, meta-analyses, and prospective studies has provided insights into more rational use of this therapy. This report describes the role of TPE for the 6 most common kidney indications in the 2013 Canadian Apheresis Group (CAG) registry and the evidence that underpins current recommendations and practice. These kidney indications include thrombotic microangiopathy, antiglomerular basement membrane disease, anti-neutrophil cytoplasmic antibody-associated vasculitis, cryoglobulinemia, recurrence of focal and segmental glomerulosclerosis in the kidney allograft, and kidney transplantation.
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16
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Kandus A, Ponikvar R, Buturović-Ponikvar J, Bren AF, Oblak M, Mlinšek G, Kmetec A, Arnol M. Plasmapheresis and Immunoadsorption for Treatment and Prophylaxis of Recurrent Focal Segmental Glomerulosclerosis in Adult Recipients of Deceased Donor Renal Grafts. Ther Apher Dial 2013; 17:438-43. [DOI: 10.1111/1744-9987.12093] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Rafael Ponikvar
- Department of Nephrology; University Medical Centre Ljubljana; Ljubljana; Slovenia
| | | | | | - Manca Oblak
- Department of Nephrology; University Medical Centre Ljubljana; Ljubljana; Slovenia
| | - Gregor Mlinšek
- Department of Nephrology; University Medical Centre Ljubljana; Ljubljana; Slovenia
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17
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Shishido S, Satou H, Muramatsu M, Hamasaki Y, Ishikura K, Hataya H, Honda M, Asanuma H, Aikawa A. Combination of pulse methylprednisolone infusions with cyclosporine-based immunosuppression is safe and effective to treat recurrent focal segmental glomerulosclerosis after pediatric kidney transplantation. Clin Transplant 2013; 27:E143-50. [PMID: 23383697 DOI: 10.1111/ctr.12079] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recurrence of focal segmental glomerulosclerosis (FSGS) in pediatric kidney allografts is associated with poor graft survival. Several therapeutic regimens have been proposed, with conflicting results. METHODS Ten pediatric patients with recurrent FSGS after kidney transplantation were treated with a protocol of methylprednisolone (MP) infusions in combination with cyclosporine (CsA)-based immunosuppression. The patients received a drug regimen with infusions of 20 mg/kg MP on three consecutive days at week 1, week 3, and week 5, and then monthly until six months after transplantation. If a complete or partial remission (PR) was obtained, MP pulse continued every three months until 24 months after transplantation. The CsA dose was adjusted according to AUC0-4. RESULTS Seven of 10 patients (70%) achieved complete remission (CR) with stable renal function within 18 months of beginning of treatment. One of two patients with PR entered CR 3.5 yr after transplantation. One patient lost her graft due to recurrence four months after transplantation. After observation for 26-119 months, seven patients maintained remission with normal glomerular filtration rate. Few major side effects were observed in association with the high-dose MP infusion therapy. CONCLUSIONS MP infusion therapy in combination with CsA-based immunosuppression could be safe and effective in treating recurrent FSGS after kidney transplantation.
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Affiliation(s)
- Seiichiro Shishido
- Department of Pediatric Nephrology, School of Medicine, Toho University, Tokyo, Japan.
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Abstract
The provision of therapeutic apheresis to children is a technically challenging procedure, requiring trained personnel and an understanding of the disease processes that leads to the need for apheresis. Most apheresis protocols are derived from studies in adult patients, even though most studies are of limited sample size. The focus of this review is to highlight the disease processes commonly treated with therapeutic apheresis in children, and to address the technical considerations pertinent to the provision of safe and effective apheresis in the pediatric setting.
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Affiliation(s)
- Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine and the Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45206, USA.
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Keith DS. Therapeutic apheresis rescue mission: recurrent focal segmental glomerulosclerosis in renal allografts. Semin Dial 2011; 25:190-2. [PMID: 22175233 DOI: 10.1111/j.1525-139x.2011.01031.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Recurrent idiopathic focal segmental glomerulosclerosis (FSGS) after renal transplantation can lead to a rapid failure of the allograft. A circulating, nonimmunoglobulin factor appears to be important in the pathogenesis of this complication in many cases. Between 30% and 50% of transplant recipients with FSGS develop recurrent disease. Three major risk factors for recurrence have been identified: short duration of native kidney disease, history of recurrence with previous kidney transplant, and pediatric aged recipients. Although no properly controlled trials have been conducted, plasmapheresis has emerged as one of the important treatment modalities for this entity. Retrospective studies prior to the routine use of plasmapheresis showed graft loss rates as high as 80%, a rate much higher than that seen in more recent series managed with plasmapheresis. Duration and intensity of treatment of plasmaphersis have not been studied rigorously, but in most case series, plasmapheresis was continued until a clear diminution of proteinuria was seen. The benefit of other adjuvant therapies for this condition remains unclear, but also may play a role in the treatment of this entity.
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Affiliation(s)
- Douglas Scott Keith
- Department of Medicine, University of Virginia Medical Center, Charlottesville, Virginia 22908-0133, USA.
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Noorlander I, Hesselink DA, Wabbijn M, Betjes MGH. High cut-off haemodialysis induces remission of recurrent idiopathic focal segmental glomerulosclerosis after renal transplantation but is no alternative to plasmapheresis. Clin Kidney J 2011; 4:321-323. [PMID: 21969845 PMCID: PMC3182260 DOI: 10.1093/ndtplus/sfr084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 06/17/2011] [Indexed: 11/14/2022] Open
Abstract
A 26-year-old male experienced a recurrence of idiopathic focal segmental glomerulosclerosis (iFSGS) after his second renal transplant. Reduction of proteinuria was rapidly induced by plasmapheresis (PP) and the patient has remained in remission with a once-weekly PP regimen, which has now been continued for >3½ years. We were also able to induce remission of iFSGS in this patient by treatment with high cut-off haemodialysis using the Theralite™ dialyser. This observation lends support for the pathophysiological role of an as yet unknown, circulating glomerular filtration barrier permeability factor with an estimated weight of between 30 and 50 kDa.
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Affiliation(s)
- Iris Noorlander
- Division of Nephrology and Renal Transplantation, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
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Abstract
The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.
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Pardon A, Audard V, Caillard S, Moulin B, Desvaux D, Bentaarit B, Remy P, Sahali D, Roudot-Thoraval F, Lang P, Grimbert P. Risk factors and outcome of focal and segmental glomerulosclerosis recurrence in adult renal transplant recipients. Nephrol Dial Transplant 2005; 21:1053-9. [PMID: 16364987 DOI: 10.1093/ndt/gfk005] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recurrence of nephrotic syndrome (NS) after renal transplantation for primary focal segmental glomerulosclerosis (FSGS) is a frequent and still unpredictable complication. However, risk factors for recurrence have not yet been clearly identified. METHODS Data from 33 patients who underwent 35 renal transplantations for FSGS in two French centres are reported. RESULTS Recurrent NS occurred in 12 transplant recipients (34%). A significantly higher number of patients in the group with recurrence (R group) compared with the group without recurrence (NR group) received cyclosporine for FSGS treatment before transplantation (83.3% vs 43.4%, P<0.02). Donors of R group recipients were significantly older than those of the non-NR group recipients (42.8 years vs 35 years, P<0.05). A higher number of patients from the R group required post-transplantation dialysis (33.3% vs 17.4%, P = 0.002). Surprisingly, acute rejection occurred more frequently in patients of the NR group compared with the R group, although the difference was not significant. Among the 12 patients with NS relapse, 9 were treated with plasmapheresis. Graft loss related to recurrence occurred in 6 cases. The 5-year graft survival was significantly lower in patients with recurrent NS compared with patients without recurrence (57% vs 82%, P<0.001). CONCLUSION This study confirms the benefit to identify in the future clinical or biological predictive risk factors for NS recurrence after renal transplantation. It also indicates that donor age is a reliable risk factor for recurrence in adult recipients and suggests for the first time a possible opposite relationship between recurrent FSGS and acute rejection.
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Affiliation(s)
- Agathe Pardon
- Department of Nephrology and Transplantation, Hôpital Henri Mondor, Créteil, France
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Koushik R, Matas AJ. Focal segmental glomerular sclerosis in kidney allograft recipients: an evidence-based approach. Transplant Rev (Orlando) 2005. [DOI: 10.1016/j.trre.2005.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Raafat RH, Kalia A, Travis LB, Diven SC. High-dose oral cyclosporin therapy for recurrent focal segmental glomerulosclerosis in children. Am J Kidney Dis 2004; 44:50-6. [PMID: 15211437 DOI: 10.1053/j.ajkd.2004.03.028] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Focal segmental glomerular sclerosis (FSGS) has a high propensity for recurrence after renal transplantation, with a 50% risk for graft failure from recurrent disease. METHODS We report on the efficacy of high-dose oral cyclosporin A (CsA) in the treatment of recurrent FSGS in children. Between August 1991 and January 2003, a total of 24 patients with FSGS underwent transplantation at 1 institution. Sixteen patients (67%) had recurrent disease. In these 16 patients, CsA dose was increased gradually until remission was achieved or there was evidence of renal toxicity. Seven patients also underwent plasma exchange. RESULTS Thirteen patients (81%) achieved remission. Remission was complete in 11 patients and partial in 2 patients. The CsA dose necessary for inducing remission ranged from 6 to 25 mg/kg/d. Four of these patients also underwent plasma exchange. After remission, CsA dose was reduced gradually toward the standard posttransplantation regimen. Eleven of 13 responders have a functioning graft after a follow-up ranging from 10 months to 12 years. One graft was lost because of recurrent FSGS, and another graft because of recurrence and cellular rejection; noncompliance was a factor in both losses. The 3 patients with disease that did not respond to high-dose CsA therapy lost their grafts because of recurrent FSGS. A common factor in these 3 patients was the inability to increase the CsA dose because of early evidence of nephrotoxicity, evidenced by an increase in serum creatinine level. CONCLUSION High-dose oral CsA therapy is effective in producing long-lasting remission of recurrent nephrotic syndrome in children with FSGS.
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Affiliation(s)
- Reem H Raafat
- Division of Pediatric Nephrology, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
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Floege J. Recurrent glomerulonephritis following renal transplantation: an update. Nephrol Dial Transplant 2003; 18:1260-5. [PMID: 12808159 DOI: 10.1093/ndt/gfg102] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jürgen Floege
- Division of Nephrology and Immunology, University of Aachen, Germany.
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Abstract
The pathologic diagnosis of focal segmental glomerulosclerosis (FSGS) is associated with a syndrome of steroid-resistant nephrotic syndrome and progressive renal insufficiency. The incidence of FSGS has increased in recent years. Known causes of FSGS include genetic abnormalities, viral infections, decreased nephron number, and hyperperfusion/hyperfiltration. The etiology is unknown in the majority of cases. FSGS recurs after initial renal transplantation in as many as 30% to 50% of patients. Recent studies have verified the hypothesis that plasma of patients with FSGS contains a factor or factors that increase permeability of glomerular capillaries and cause proteinuria after injection into rats. Patients who experience posttransplant recurrence of FSGS and those with rapidly progressive disease exhibit this activity. Permeability activity has been verified in functional assays and defined by measurement of albumin permeability (P(alb)) or glomerular volume variation (GVV). Permeability activity is decreased by plasmapheresis or immunoadsorption and can be recovered from discarded plasma or eluate from adsorption materials. Studies from our laboratory indicate that permeability activity is carried by small, highly glycosylated, hydrophobic protein(s)/peptide(s). Normal plasma contains substances capable of blocking or inactivating the FSGS permeability factor. Pharmacologic agents including cyclosporine, indomethacin, and derivatives of Trypterigium wilfordii also block permeability activity in vitro. The observation that permeability activity can be blocked by diverse agents raises hope that specific therapy may be designed for FSGS. Future investigations will permit identification of the active FSGS permeability factor, of mechanisms that initiate and perpetuate proteinuria, and of interventions to prevent renal failure in native kidneys and recurrence of disease in renal allografts.
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Affiliation(s)
- Virginia J Savin
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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Ponticelli C, Campise M, Tarantino A. The different patterns of response to plasmapheresis of recurrent focal and segmental glomerulosclerosis. Transplant Proc 2002; 34:3069-71. [PMID: 12493377 DOI: 10.1016/s0041-1345(02)03655-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- C Ponticelli
- U.O. Nefrologia IRCCS Ospedale Maggiore, Milano, Italy.
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