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Raina R, Jothi S, Haffner D, Somers M, Filler G, Vasistha P, Chakraborty R, Shapiro R, Randhawa PS, Parekh R, Licht C, Bunchman T, Sethi S, Mangat G, Zaritsky J, Schaefer F, Warady B, Bartosh S, McCulloch M, Alhasan K, Swiatecka-Urban A, Smoyer WE, Chandraker A, Yap HK, Jha V, Bagga A, Radhakrishnan J. Post-transplant recurrence of focal segmental glomerular sclerosis: consensus statements. Kidney Int 2024; 105:450-463. [PMID: 38142038 DOI: 10.1016/j.kint.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 10/03/2023] [Accepted: 10/17/2023] [Indexed: 12/25/2023]
Abstract
Focal segmental glomerular sclerosis (FSGS) is 1 of the primary causes of nephrotic syndrome in both pediatric and adult patients, which can lead to end-stage kidney disease. Recurrence of FSGS after kidney transplantation significantly increases allograft loss, leading to morbidity and mortality. Currently, there are no consensus guidelines for identifying those patients who are at risk for recurrence or for the management of recurrent FSGS. Our work group performed a literature search on PubMed/Medline, Embase, and Cochrane, and recommendations were proposed and graded for strength of evidence. Of the 614 initially identified studies, 221 were found suitable to formulate consensus guidelines for recurrent FSGS. These guidelines focus on the definition, epidemiology, risk factors, pathogenesis, and management of recurrent FSGS. We conclude that additional studies are required to strengthen the recommendations proposed in this review.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA; Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Swathi Jothi
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Michael Somers
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Guido Filler
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Prabhav Vasistha
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Ronith Chakraborty
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA; Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Ron Shapiro
- Recanati/Miller Transplantation Institute, The Mount Sinai Medical Center, New York, New York, USA
| | - Parmjeet S Randhawa
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rulan Parekh
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christopher Licht
- Division of Pediatric Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Timothy Bunchman
- Pediatric Nephrology and Transplantation, Children's Hospital of Richmond at Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Guneive Mangat
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Joshua Zaritsky
- Division of Pediatric Nephrology, Nemours, A.I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Franz Schaefer
- Department of Pediatric Nephrology, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Bradley Warady
- Division of Nephrology, University of Missouri-Kansas City School of Medicine, Children's Mercy, Kansas City, Missouri, USA
| | - Sharon Bartosh
- Department of Pediatrics, University of Wisconsin Medical School, Madison, Wisconsin, USA
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Khalid Alhasan
- Nephrology Unit, Pediatrics Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Pediatric Kidney Transplant Division, Organ Transplant Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Agnieszka Swiatecka-Urban
- University of Virginia Children's Hospital, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - William E Smoyer
- Center for Clinical and Translational Research and Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Anil Chandraker
- Transplantation Research Center, Kidney and Pancreas Transplantation, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hui Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales (UNSW), New Delhi, India; School of Public Health, Imperial College, London, UK; Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Arvind Bagga
- Division of Pediatric Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Jai Radhakrishnan
- Department of Medicine (Nephrology), Columbia University Medical Center, New York, New York, USA.
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2
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Rheault MN, Amaral S, Bock M, Chambers ET, Chavers B, Ters ME, Garro R, Gbadegesin R, Govil A, Harshman L, Amer H, Hooper DK, Israni AK, Riad S, Sageshima J, Shapiro R, Seifert M, Smith J, Sung R, Thomas CP, Wang Q, Verghese PS. A randomized controlled trial of preemptive rituximab to prevent recurrent focal segmental glomerulosclerosis post-kidney transplant (PRI-VENT FSGS): protocol and study design. FRONTIERS IN NEPHROLOGY 2023; 3:1181076. [PMID: 37675355 PMCID: PMC10479749 DOI: 10.3389/fneph.2023.1181076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/17/2023] [Indexed: 09/08/2023]
Abstract
Background Focal segmental glomerulosclerosis (FSGS) is a common cause of end-stage kidney disease requiring kidney transplantation and can recur in the allograft in 30-80% of recipients resulting in reduced graft survival. Plasmapheresis has shown efficacy in treating some cases of recurrent FSGS but isolated plasmapheresis has not demonstrated efficacy in preventing recurrent FSGS. Rituximab has had anecdotal success in preventing recurrence in a single center study but has not been studied in combination with plasmapheresis for preventing FSGS recurrence. Methods We are conducting a randomized, controlled, multicenter clinical trial of adult and pediatric kidney transplant recipients with primary FSGS to assess whether plasmapheresis in combination with rituximab prevents recurrent disease post-transplantation. Discussion Rituximab combined with plasmapheresis is a promising, novel therapy to prevent recurrent FSGS, a disease with limited therapeutic options and no consensus guidelines for prevention or treatment. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT03763643, identifier NCT03763643.
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Affiliation(s)
- Michelle N. Rheault
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Sandra Amaral
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Margret Bock
- Department of Pediatrics, Children’s Hospital of Colorado, Denver, CO, United States
| | | | - Blanche Chavers
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Mireile El Ters
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Rouba Garro
- Department of Pediatrics, Emory University, Atlanta, GA, United States
| | | | - Amit Govil
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Lyndsay Harshman
- Department of Pediatrics, University of Iowa, Iowa, IA, United States
| | - Hatem Amer
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - David K. Hooper
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Ajay K. Israni
- The Kidney Center at Hennepin Healthcare, Hennepin Health, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Samy Riad
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Junichiro Sageshima
- Department of Surgery, University of California, Davis, Davis, CA, United States
| | - Ron Shapiro
- Department of Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, United States
| | - Michael Seifert
- Heersink School of Medicine, Department of Pediatrics, School of Medicine, University of Alabama, Birmingham, AL, United States
| | - Jodi Smith
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA, United States
| | - Randall Sung
- Department of Surgery, University of Michigan Health, Ann, Arbor, MI, United States
| | - Christie P. Thomas
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Qi Wang
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, United States
| | - Priya S. Verghese
- Department of Pediatrics, Northwestern University, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL, United States
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3
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Harshman LA, Bartosh S, Engen RM. Focal segmental glomerulosclerosis: Risk for recurrence and interventions to optimize outcomes following recurrence. Pediatr Transplant 2022; 26:e14307. [PMID: 35587003 DOI: 10.1111/petr.14307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND FSGS is a common indication for kidney transplant with a high-risk of posttransplant recurrence. METHODS In this review, we summarize current knowledge about FSGS recurrence after kidney transplantation, including epidemiology, pretransplant planning, posttransplant management, and investigational treatments. RESULTS FSGS recurs in 14%-60% of first transplants, likely associated with a circulating permeability factor. Pretransplant counseling regarding recurrence is critical, and patients with FSGS should undergo pretransplant genetic screening. Rapid progression to ESKD, initial steroid responsiveness, younger age at diagnosis, race/ethnicity, and mesangial hypercellularity or minimal change histology on native biopsy may be associated with recurrence. Living donation is not contraindicated but does not result in improved graft survival relative to deceased donation. Pretransplant nephrectomy may be performed for a variety of reasons, but does not decrease recurrence. Pretransplant therapy with rituximab and/or PE is understudied but not clearly effective at preventing recurrence. Patients with FSGS typically present early with rapid-onset severe proteinuria. Diagnosis can be confirmed by biopsy showing foot process effacement; typical FSGS lesions are not seen on light microscopy in the early stages. There is no established effective treatment for recurrent FSGS, but renin-angiotensin-aldosterone system inhibition and extracorporeal therapies, including PE and IA, are most commonly used. Adjunct or alternative therapies may include rituximab, lipopheresis, and cyclosporine.
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Affiliation(s)
- Lyndsay A Harshman
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Sharon Bartosh
- University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Rachel M Engen
- University of Wisconsin Madison, Madison, Wisconsin, USA
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4
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Verghese PS, Rheault MN, Jackson S, Matas AJ, Chinnakotla S, Chavers B. The effect of peri-transplant plasmapheresis in the prevention of recurrent FSGS. Pediatr Transplant 2018; 22:e13154. [PMID: 29388290 DOI: 10.1111/petr.13154] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2017] [Indexed: 12/20/2022]
Abstract
Many pediatric centers utilize a variety of protocols including preemptive plasmapheresis to prevent the recurrence of FSGS post-transplant. But the effectiveness of this expensive, time-consuming process of plasmapheresis in the prevention of FSGS recurrence is still unclear. We retrospectively reviewed all pediatric cases of FSGS in our center that received a kidney transplant and compared the transplant and patient outcomes of those transplanted after 2006 who received pretransplant plasmapheresis to those prior to 2006 who did not. Of the 57 children with FSGS, 31 and 26 were transplanted before and after 2006, respectively. The cohorts differed significantly in keeping with the center immunosuppression protocol changes, and prior to 2006, the recipients were significantly younger. All children with FSGS transplanted after 2006 underwent three and one sessions of 1.0 plasma volume/exchange plasmapheresis with fresh frozen plasma replacement prior to the transplant in living and deceased donors, respectively, in addition to five sessions of every other day post-transplant pheresis. The incidence (27% vs 26%, P = 1.0) and time to recurrence of FSGS in the kidney allograft (P = .22) were not significantly different in patients that did and did not undergo prophylactic plasmapheresis. We need to re-evaluate the role of preemptive plasmapheresis in the prevention of FSGS recurrence in a prospective multicenter study.
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Affiliation(s)
- P S Verghese
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - M N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - S Jackson
- Informatics Services for Research and Reporting, M Health, Minneapolis, MN, USA
| | - A J Matas
- Department of Surgery, Division of Transplant Surgery, University of Minnesota, Minneapolis, MN, USA
| | - S Chinnakotla
- Department of Surgery, Division of Transplant Surgery, University of Minnesota, Minneapolis, MN, USA
| | - B Chavers
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
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5
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Abbas F, El Kossi M, Jin JK, Sharma A, Halawa A. Recurrence of primary glomerulonephritis: Review of the current evidence. World J Transplant 2017; 7:301-316. [PMID: 29312859 PMCID: PMC5743867 DOI: 10.5500/wjt.v7.i6.301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 09/24/2017] [Accepted: 11/22/2017] [Indexed: 02/05/2023] Open
Abstract
In view of the availability of new immunosuppression strategies, the recurrence of allograft glomerulonephritis (GN) are reported to be increasing with time post transplantation. Recent advances in understanding the pathogenesis of the GN recurrent disease provided a better chance to develop new strategies to deal with the GN recurrence. Recurrent GN diseases manifest with a variable course, stubborn behavior, and poor response to therapy. Some types of GN lead to rapid decline of kidney function resulting in a frustrating return to maintenance dialysis. This subgroup of aggressive diseases actually requires intensive efforts to ascertain their pathogenesis so that strategy could be implemented for better allograft survival. Epidemiology of native glomerulonephritis as the cause of end-stage renal failure and subsequent recurrence of individual glomerulonephritis after renal transplantation was evaluated using data from various registries, and pathogenesis of individual glomerulonephritis is discussed. The following review is aimed to define current protocols of the recurrent primary glomerulonephritis therapy.
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Affiliation(s)
- Fedaey Abbas
- Department of Nephrology, Jaber El Ahmed Military Hospital, Safat 13005, Kuwait
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Jon Kim Jin
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Nottingham Children Hospital, Nottingham NG7 2UH, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Transplantation Surgery, Sheffield Teaching Hospitals, Sheffield S5 7AU, United Kingdom
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6
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Allard L, Kwon T, Krid S, Bacchetta J, Garnier A, Novo R, Deschenes G, Salomon R, Roussey G, Allain-Launay E. Treatment by immunoadsorption for recurrent focal segmental glomerulosclerosis after paediatric kidney transplantation: a multicentre French cohort. Nephrol Dial Transplant 2017; 33:954-963. [DOI: 10.1093/ndt/gfx214] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 05/10/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lise Allard
- CHU d’Angers, Pôle Femme-Mère-Enfant, Service de Pédiatrie, Angers, France
| | - Theresa Kwon
- Hôpital Robert Debré, Service de Néphrologie et Hémodialyse Pédiatrique, Paris, France
| | - Saoussen Krid
- Hôpital Necker Enfants Malades, Service de Néphrologie Pédiatrique, Paris, France
| | - Justine Bacchetta
- Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Lyon, France
| | - Arnaud Garnier
- Hôpitaux de Toulouse, Hôpital des Enfants, Service de Néphrologie, Médecine Interne et Hypertension, Toulouse, France
| | - Robert Novo
- CHRU Lille, Hôpital Jeanne de Flandre, Service de Néphrologie Pédiatrique, Lille, France
| | - Georges Deschenes
- Hôpital Robert Debré, Service de Néphrologie et Hémodialyse Pédiatrique, Paris, France
| | - Rémi Salomon
- Hôpital Necker Enfants Malades, Service de Néphrologie Pédiatrique, Paris, France
| | - Gwenaëlle Roussey
- CHU Nantes, Hôpital Mère-Enfants, Néphrologie et Hémodialyse Pédiatrique, Nantes, France
| | - Emma Allain-Launay
- CHU Nantes, Hôpital Mère-Enfants, Néphrologie et Hémodialyse Pédiatrique, Nantes, France
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7
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FSGS Recurrence in Adults after Renal Transplantation. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3295618. [PMID: 27144163 PMCID: PMC4842050 DOI: 10.1155/2016/3295618] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 03/27/2016] [Indexed: 12/18/2022]
Abstract
Recurrence of focal segmental glomerulosclerosis (FSGS) in the allograft occurs in 30–50% of patients, and it is associated with poor renal allograft survival. Major risk factors for recurrence are younger age at diagnosis, rapid progression to end-stage renal disease, white race, and the loss of previous allografts due to recurrence. Recent data support the hypothesis that circulating permeability factors play a crucial role in podocyte injury and progression of FSGS. Due to lack of controlled trials, the management of recurrent FSGS is inconsistent and highly empirical. Prophylactic and perioperative treatment with plasmapheresis and high-dose (intravenous) cyclosporine represent the main cornerstones of immunosuppressive therapy. In recent years, therapy with rituximab has shown promising results. Despite evidence of activation of the renin-angiotensin system (RAS) in recurrent FSGS and its association with progression, only limited data exist on the renoprotective role of RAS blockade in this setting. Further well designed studies are needed on pathogenesis risk factors and therapeutical options in FSGS and its recurrence after transplantation.
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8
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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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9
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Cravedi P, Kopp JB, Remuzzi G. Recent progress in the pathophysiology and treatment of FSGS recurrence. Am J Transplant 2013; 13:266-74. [PMID: 23312002 PMCID: PMC3558619 DOI: 10.1111/ajt.12045] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 11/05/2012] [Accepted: 11/06/2012] [Indexed: 01/25/2023]
Abstract
Focal segmental glomerulosclerosis (FSGS) is a glomerular disease characterized by proteinuria, frequent progression to end-stage renal disease, and recurrence after kidney transplantation in ∼25% of patients, which negatively impacts long-term allograft survival. Experimental studies suggest that abnormalities in T and, possibly, B cells may represent one initial pathogenic trigger, leading to podocyte injury and progressive loss. New data also support the existence of circulating permeability factors able to damage the podocytes, but no single molecule has been consistently identified as the causal pathogenic element in FSGS recurrence. Unfortunately, major progress from mechanistic studies has not translated into substantial advancements in patient treatment, with plasmapheresis (PP) and high doses of cyclosporine (CsA) remaining the mainstays of therapy. Despite consistent experimental and clinical evidence that treatment of proteinuria slows renal function decline in proteinuric nephropathies, maximal use of antiproteinuric agents such as renin angiotensin system antagonists is not routine in the management of FSGS recurrence. More recently, encouraging results have been reported with anti-CD20 depleting antibody rituximab, but further studies are needed to establish its safety/efficacy profile.
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Affiliation(s)
- Paolo Cravedi
- Mario Negri Institute for Pharmacological Research, Clinical Research Center for Rare Diseases “Aldo e Cele Dacco”, Villa Camozzi, Ranica, Bergamo, Italy
| | - Jeffrey B. Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Giuseppe Remuzzi
- Mario Negri Institute for Pharmacological Research, Clinical Research Center for Rare Diseases “Aldo e Cele Dacco”, Villa Camozzi, Ranica, Bergamo, Italy,Unit of Nephrology, Azienda Ospedaliera Ospedali Riuniti di Bergamo, Bergamo, Italy
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10
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Savin VJ, McCarthy ET, Sharma M. Permeability factors in nephrotic syndrome and focal segmental glomerulosclerosis. Kidney Res Clin Pract 2012; 31:205-13. [PMID: 26889423 PMCID: PMC4716100 DOI: 10.1016/j.krcp.2012.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/25/2012] [Accepted: 10/04/2012] [Indexed: 12/23/2022] Open
Abstract
Circulating permeability factors have been identified in the plasma of patients with focal segmental glomerulosclerosis (FSGS). Post-transplant recurrence of proteinuria, improvement of proteinuria after treatment with plasmapheresis, and induction of proteinuria in experimental animals by plasma fractions each provide evidence for such plasma factors. Advanced proteomic methods have identified candidate molecules in recurrent FSGS. We have proposed cardiotrophin-like cytokine-1 as an active factor in FSGS. Another potential permeability factor in FSGS is soluble urokinase receptor. In our studies, in vitro plasma permeability activity is blocked by substances that may decrease active molecules or block their effects. We have shown that the simple sugar galactose blocks the effect of FSGS serum in vitro and decreases permeability activity when administered to patients. Since the identities of permeability factors and their mechanisms of action are not well defined, treatment of FSGS is empiric. Corticosteroids are the most common agents for initial treatment. Calcineurin inhibitors, such as cyclosporine A, and tacrolimus and immunosuppressive medications, including mycophenylate, induce remission is some patients with steroid-resistant or -dependent nephrotic syndrome. Therapies that diminish proteinuria and slow progression in FSGS as well as other conditions include renin-angiotensin blockade, blood pressure lowering and plasma lipid control. Use of findings from in vitro studies, coupled with definitive identification of pathogenic molecules, may lead to new treatments to arrest FSGS progression and prevent recurrence after transplantation.
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Affiliation(s)
- Virginia J Savin
- Kansas City Veterans Administration Medical Center, Kansas City, MO, United States
| | - Ellen T McCarthy
- Kansas City Veterans Administration Medical Center, Kansas City, MO, United States
| | - Mukut Sharma
- Kansas City Veterans Administration Medical Center, Kansas City, MO, United States
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11
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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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12
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Vinai M, Waber P, Seikaly MG. Recurrence of focal segmental glomerulosclerosis in renal allograft: an in-depth review. Pediatr Transplant 2010; 14:314-25. [PMID: 20519016 DOI: 10.1111/j.1399-3046.2009.01261.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Focal segmental glomerulosclerosis is a major cause of chronic kidney disease requiring transplantation in children. Recurrence rate in the renal allograft transplantation is as high as 50%. Recurrence of FSGS is associated with renal dysfunction and early graft loss. To date, there is no established therapy for recurrent FSGS after renal transplant. We have reviewed the current English literature in order to summarize current practices with emphasis on graft outcome. We conclude that despite multiple approaches to the post transplant management of recurrent FSGS, none have been shown to be consistently beneficial. Currently, pheresis combined with high dose anti-calcineurin with or without rituximab seems to be the most promising. Further controlled studies are needed to define the optimal therapeutic regimens to treat recurrent of FSGS.
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Affiliation(s)
- Modini Vinai
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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13
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Long-term outcome of focal segmental glomerulosclerosis after pediatric renal transplantation. Pediatr Nephrol 2010; 25:529-34. [PMID: 19956977 DOI: 10.1007/s00467-009-1361-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 09/27/2009] [Accepted: 10/01/2009] [Indexed: 10/20/2022]
Abstract
Recurrence of focal segmental glomerulosclerosis (FSGS) after renal transplantation can limit graft survival. Despite new immunosuppressive agents, the incidence of recurrence remains relatively high. To identify risk factors for recurrence and efficacy of treatment, we reviewed the outcome of 23 grafts in 16 children with FSGS who had undergone transplantation between 1985 and 2007 at La Paz Children's Hospital. Recurrence was 56.3% after the first transplantation. We did not find significant differences in age at diagnosis, age at transplantation, age at end-stage renal disease (ESRD), progression to ESRD, bilateral nephrectomy of native kidneys prior to transplantation, use of induction therapy or of different immunosuppressive regimens between patients with and without recurrence. Plasmapheresis (PP) was carried out in seven of nine patients who had suffered recurrence, achieving remission in six of them. One patient received high doses of cyclosporin (CsA) and plasmapheresis, attaining remission. Graft survival was lower (P = 0.043) in patients with FSGS than in those with other ESRD etiologies (first year 75% vs 91%; fifth year 44% vs 78%). Recurrence of FSGS limited graft survival (first year 66% vs 85%; third year 20% vs 68%) (P = 0.07). In our experience, PP can be effective in treating FSGS recurrence, although its effect on long-term graft survival seems more limited.
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Canaud G, Zuber J, Sberro R, Royale V, Anglicheau D, Snanoudj R, Gaha K, Thervet E, Lefrère F, Cavazzana-Calvo M, Noël LH, Méjean A, Legendre C, Martinez F. Intensive and prolonged treatment of focal and segmental glomerulosclerosis recurrence in adult kidney transplant recipients: a pilot study. Am J Transplant 2009; 9:1081-6. [PMID: 19344432 DOI: 10.1111/j.1600-6143.2009.02580.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
No treatment has consistently induced long-term remission of proteinuria in adult patients with focal segmental glomerulosclerosis (FSGS) recurrence after kidney transplantation. We undertook an open-label, nonrandomized pilot trial of intensive and prolonged treatment of FSGS recurrence. Over an 18-month period, 10 adult kidney transplant recipients with FSGS recurrence received concomitantly high-dose steroids, intravenous cyclosporine for 14 days followed by oral cyclosporine therapy, and an intensive and prolonged course of plasma exchanges (PE). We compared this treatment with those of a control group of 19 patients with a FSGS recurrence transplanted between 1997 and 2005. Complete, rapid (mean 23 +/- 7 days) and sustained remission was obtained in 9/10 patients (90%) as opposed to 27% in the control group. At month 3 and month 12, proteinuria was 0.16 g/day (range 0.05-0.3 g/day) and 0.19 g/day (range 0.05-1 g/day) respectively. Only one patient remained in partial remission at month 12 but he had already lost two previous grafts due to FSGS recurrence. PEs were stopped at month 9 in all patients except for the patient with a partial remission who remains PE-dependent. This small pilot study provides very encouraging results demonstrating that this treatment rapidly achieves complete and sustained remission in a high proportion of patients.
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Affiliation(s)
- G Canaud
- Université Paris Descartes, 7 Rue de l'Ecole de Médecine, Paris 75007, France.
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Imaizumi T, Kawasaki Y, Matsuura H, Matsumoto A, Takano K, Suyama K, Hashimoto K, Suzuki H, Hosoya M. Efficacy of steroid pulse, plasmapheresis, and mizoribine in a patient with focal segmental glomerulosclerosis. Pediatr Nephrol 2007; 22:1215-8. [PMID: 17347835 DOI: 10.1007/s00467-007-0461-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Revised: 02/01/2007] [Accepted: 02/02/2007] [Indexed: 11/30/2022]
Abstract
There have been few reports on successful treatment for focal segmental glomerulosclerosis (FSGS) complicated by leukoencephalopathy. We report the efficacy of the steroid pulse and mizoribine (MZB) combined with plasmapheresis (PP) for a case of FSGS with leukoencephalopathy induced by cyclosporine (CyA). The patient was a 4-year-old boy with FSGS who presented with steroid-resistant nephrotic syndrome (NS) and was treated with CyA. On the 7th day after starting CyA, he complained of one visual disorder, and hypertension and tonic convulsions were observed. Electroencephalography (EEG) revealed generalized slow waves, and magnetic resonance imaging (MRI) disclosed high signal intensity in the white matter. A diagnosis of leukoencephalopathy induced by CyA was made on the basis of these findings with the improvement in clinical manifestations upon discontinuation of CyA. We treated the patient with steroid pulse therapy and MZB combined with PP, and the proteinuria gradually decreased and only microscopic hematuria remained. We report that steroid pulse and MZB combined with PP may be an effective treatment in a patient with FSGS complicated by CyA-induced leukoencephalopathy.
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Affiliation(s)
- Tomoko Imaizumi
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan.
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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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Hubsch H, Montané B, Abitbol C, Chandar J, Shariatmadar S, Ciancio G, Burke G, Miller J, Strauss J, Zilleruelo G. Recurrent focal glomerulosclerosis in pediatric renal allografts: the Miami experience. Pediatr Nephrol 2005; 20:210-6. [PMID: 15605284 DOI: 10.1007/s00467-004-1706-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2003] [Revised: 08/26/2004] [Accepted: 09/10/2004] [Indexed: 11/30/2022]
Abstract
Recurrence of focal glomerulosclerosis (FSGS) following renal transplantation is a common cause of allograft loss and clinical morbidity. Recent attempts to control proteinuria and morbidity with plasmapheresis (PP) have met with limited success. Our experience with the use of mycophenolate mofetil (MMF) and angiotensin blockade (AB) in the management of refractory FSGS pre transplant suggested its potential benefit in post-transplant recurrence. This report presents our 25-year experience in pediatric renal transplantation of patients with FSGS divided into two treatment eras: Era 1-prior to use of daclizumab (anti-IL-2R) and Era 2-after daclizumab. A total of 179 pediatric patients were transplanted during the 25-year period. FSGS was confirmed in 27 (15%); 16 of 28 allografts (57%) had recurrence of FSGS during the post-transplant period. In Era 1, only 6 of 16 (38%) recurred in the allograft, while 10 of 12 (83%) recurred during Era 2. The odds ratio of recurrence of FSGS in the allograft after induction with anti-IL-2R was 8.3 (95% confidence interval=1.3-52, P =0.02). Only 2 patients in Era 1 received PP, while 10 in Era 2 were entered into an intensive PP protocol followed by maintenance with AB consisting of angiotensin receptor blockers alone, or in combination with angiotensin-converting enzyme inhibitor. Although proteinuria decreased an average of 80+/-16% with PP, the response was variable and severe morbid edema persisted in poor responders. Maximum benefit occurred with the addition of AB and MMF. After a follow-up of 27+/-15 months, proteinuria has shown a sustained decrease of 94+/-8% below baseline. In conclusion, our experience suggests that, with recurrent FSGS, a limited course of PP followed by maintenance therapy with AB and MMF improves symptoms and may preserve allograft function.
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Affiliation(s)
- Hans Hubsch
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960 (M-714), Miami, FL 33101, USA
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Affiliation(s)
- Roald Nezlin
- Department of Immunology, Weizmann Institute of Science, Rehovot 76100, Israel
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Abstract
Pediatric transplantation has seen remarkable advances over the past two decades with reduced morbidity and mortality, reduced rejection rates, and improved long-term patient and allograft survival. Infants currently have short-term patient and allograft survival rates better than any other age group; short-term allograft survival rates in CD recipients are equal to those in LD recipients. With decreased rejection, long-term allograft survival is improving dramatically. Transplantation allows for much reduced risks and improved metabolic status, growth and development, and more normal social interactions. The future of transplantation continues to be exciting, with opportunities for reduced immunosuppressive medications and their side effects, and the elusive goal of transplantation tolerance seems within reach.
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Affiliation(s)
- Mark R Benfield
- Division of Pediatric Nephrology, University of Alabama at Birmingham, 1600 7th Avenue S-ACC 516, Birmingham, AL 35233, 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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