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Dharnidharka VR, Scobell RR, Kallash M, Davies AJG, Marchesani N, Maltenfort MG, Walther L, Kelton M, Bock M, Blanchette E, Stone HK, Gluck C, Hullekes F, Riella LV, Smoyer WE, Mitsnefes M, Dixon BP, Flynn JT, Somers MJG, Forrest CB, Furth S, Denburg MR. Clinical characteristics and favorable treatment responses of recurrent focal segmental glomerulosclerosis or steroid-resistant nephrotic syndrome in children after kidney transplantation. Pediatr Nephrol 2024; 39:3317-3331. [PMID: 39001911 DOI: 10.1007/s00467-024-06452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Recurrence of focal segmental glomerulosclerosis (FSGS) or steroid-resistant nephrotic syndrome (SRNS) after kidney transplant leads to significant morbidity and potentially earlier allograft loss. To date however, reported rates, risk factors and treatment outcomes have varied widely. METHODS We applied computational phenotypes to a multicenter aggregation of electronic health records data from 7 large pediatric health systems in the USA, to identify recurrence rates, risk factors, and treatment outcomes. We refined the data collection by chart review. RESULTS From > 7 million patients, we compared children with primary FSGS/SRNS who received a kidney transplant between 2009 and 2020 and who either developed recurrence (n = 67/165; 40.6%) or did not (n = 98/165). Serum albumin level at time of transplant was significantly lower and recipient HLA DR7 presence was significantly higher in the recurrence group. By 36 months post-transplant, complete remission occurred in 58.2% and partial remission in 17.9%. Through 6 years post-transplant, no remission after recurrence was associated with an increased risk of allograft loss over time (p < 0.0001), but any remission showed similar allograft survival and function decline to those with no recurrence. Since treatments were used in non-random fashion, using spline curves and multivariable non-linear analyses, complete + partial remission chance was significantly higher with greater plasmapheresis sessions, CTLA4-Ig doses or LDL-apheresis sessions. Only treatment with anti-CD20, CTLA4-Ig agents, or LDL-apheresis sessions were associated with complete remission. Excluding 25 patients with mutations did not significantly change our results. CONCLUSIONS Our contemporary high-risk cohort had higher favorable response rates than most prior reports, from combinations of agents.
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Affiliation(s)
- Vikas R Dharnidharka
- Washington University School of Medicine and St. Louis Children's Hospital, Room NWT 10-119, CB 8116, 660 South Euclid Avenue, St. Louis, MO, 63110, USA.
| | | | - Mahmoud Kallash
- Department of Pediatrics, The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | | | | | | | - Leslie Walther
- Washington University School of Medicine and St. Louis Children's Hospital, Room NWT 10-119, CB 8116, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Megan Kelton
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Margret Bock
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Eliza Blanchette
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hillarey K Stone
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | - William E Smoyer
- Department of Pediatrics, The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Mark Mitsnefes
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | - Susan Furth
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle R Denburg
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Angeletti A, Bin S, Magnasco A, Bruschi M, Cravedi P, Ghiggeri GM. Efficacy of combined rituximab and daratumumab treatment in posttransplant recurrent focal segmental glomerulosclerosis. Am J Transplant 2024; 24:688-692. [PMID: 38101474 DOI: 10.1016/j.ajt.2023.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/15/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023]
Abstract
Focal segmental glomerulosclerosis (FSGS) is one of the leading causes of kidney failure and it is characterized by a high rate of recurrence after kidney transplant. Moreover, FSGS recurrence is worsened by an increased risk of graft failure. Common therapies for FSGS recurrence mostly consist of plasma exchange treatments, also for prolonged time, and rituximab, with variable efficacy. We report 5 cases of early FSGS recurrence after kidney transplant, resistant to plasma exchange and rituximab treatment that subsequently resolved after combined therapy with rituximab and daratumumab. All cases were negative for genetic FSGS. The combined treatment induced a complete response in all the cases and was well tolerated. We also performed a comprehensive flow cytometry analysis in 2 subjects that may suggest a mechanistic link between plasma cells and disease activity. In conclusion, given the lack of viable treatments for recurrent FSGS, our reports support the rationale for a pilot trial testing the safety/efficacy profile of combined rituximab and daratumumab in posttransplant FSGS recurrence.
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Affiliation(s)
- Andrea Angeletti
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Sofia Bin
- Translational Transplant Research Center and Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alberto Magnasco
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maurizio Bruschi
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Paolo Cravedi
- Translational Transplant Research Center and Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gian Marco Ghiggeri
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Ahmad SB, Peleg Y, Ahn W. Current approaches to overcome recurrent focal segmental glomerulosclerosis after kidney transplantation. Curr Opin Nephrol Hypertens 2024; 33:61-66. [PMID: 37921337 DOI: 10.1097/mnh.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
PURPOSE OF REVIEW Recurrent focal segmental glomerulosclerosis (FSGS) presents with nephrotic syndrome shortly after kidney transplantation. This review will overview the role of circulating permeability factors in disease pathogenesis and treatment options for recurrent FSGS. RECENT FINDINGS Novel circulating permeability factors have been identified in serum samples. Current research is focused on detection of permeability factors as a marker of treatment response. Furthermore, novel monoclonal antibodies are being utilized to further induce remission. SUMMARY Posttransplant recurrent FSGS can have a deleterious effect on allograft. Early detection of disease recurrence with prompt treatment is optimal for clinical remission. Plasmapheresis with anti-B cell therapy is considered the mainstay of treatment. Newer B cell therapies and detection of circulating factors in serum may help in providing targeted treatment in a subset of patients.
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Affiliation(s)
- Syeda Behjat Ahmad
- University of Pittsburgh School of Medicine, Division of Renal-Electrolyte, Pittsburgh, Pennsylvania
| | - Yonatan Peleg
- Northwestern University Feinberg School of Medicine, Division of Nephrology and Hypertension, Chicago, Illinois
| | - Wooin Ahn
- Oregon Health & Science University School of Medicine, Division of Nephrology and Hypertension, Portland, Oregon, USA
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Gipson DS, Wang CS, Salmon E, Gbadegesin R, Naik A, Sanna-Cherchi S, Fornoni A, Kretzler M, Merscher S, Hoover P, Kidwell K, Saleem M, Riella L, Holzman L, Jackson A, Olabisi O, Cravedi P, Freedman BS, Himmelfarb J, Vivarelli M, Harder J, Klein J, Burke G, Rheault M, Spino C, Desmond HE, Trachtman H. FSGS Recurrence Collaboration: Report of a Symposium. GLOMERULAR DISEASES 2024; 4:1-10. [PMID: 38348154 PMCID: PMC10859699 DOI: 10.1159/000535138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/30/2023] [Indexed: 02/15/2024]
Affiliation(s)
- Debbie S. Gipson
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Chia-Shi Wang
- Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Eloise Salmon
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Rasheed Gbadegesin
- Department of Medicine, Duke University, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Abhijit Naik
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Matthias Kretzler
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Paul Hoover
- Department of Medicine, Harvard University, Cambridge, MA, USA
| | - Kelley Kidwell
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Moin Saleem
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Leonardo Riella
- Department of Medicine, Harvard University, Cambridge, MA, USA
| | - Lawrence Holzman
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Paolo Cravedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Marina Vivarelli
- Department of Pediatric Subspecialties, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Jennifer Harder
- Department of Internal Medicine, University of Louisville, Louisville, KY, USA
| | - Jon Klein
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - George Burke
- Department of Surgery, University of Miami, Miami, FL, USA
| | - Michelle Rheault
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Hailey E. Desmond
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Howard Trachtman
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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Advances in Apheresis Techniques and Therapies in the Pediatric Setting. CURRENT PEDIATRICS REPORTS 2022. [DOI: 10.1007/s40124-022-00275-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Lin J, Sun J. Rituximab May Have Positive Effect on Refractory Nephrotic Syndrome: A Meta-Analysis of Randomized Trials. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3008597. [PMID: 35813445 PMCID: PMC9262522 DOI: 10.1155/2022/3008597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/11/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022]
Abstract
Purpose This study was aimed at demonstrating the role of rituximab (RTX) on the influence of nephrotic syndrome (NS) and on urinary protein which was not significant. Methods The clinical randomized controlled trials were performed by eight databases. Meanwhile, the confidence interval (CI) of either relative risk or mean difference was set to 95%. Besides, the heterogeneity of the research results is tested by I 2. Results A total of 1658 references were found using the search method. This meta-analysis will be done by the ultimately eight different studies. Each study is described as random controlled trial. According to these eight studies, the remission of test group and control group was quite higher (OR: 1.60; 95% Cl: 1.17, 2.20; P < 0.01) than the control group, serum albumin (SMD: 4.19; 95% Cl: 1.49, 6.89; P < 0.01), and urine protein (SMD: 0.79; 95% Cl: -0.64, 2.22; P = 0.28). Despite the fact that the remission rate's funnel plot was asymmetrically distributed, Egger's test and Begg's test revealed no probable publish bias. Conclusion The results of this study suggest that rituximab (RTX) may be effective in RNS, as evidenced by remission rates and serum albumin. However, the effect on urinary protein was not significant. The clear evidence is missing in this literature. Therefore, large sample, multicenter, low risk of bias clinical studies, as well as basic medical research, is needed.
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Affiliation(s)
- Jingjing Lin
- Nephrology Department, First People's Hospital of Linping District, Hangzhou, China
| | - Jia Sun
- Nephrology Department, First People's Hospital of Linping District, Hangzhou, China
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