1
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Ban H, Miura K, Ando T, Shirai Y, Kaneko N, Ishizuka K, Hotta K, Hattori M. Clinical Course of Nonresponders With Recurrent Focal Segmental Glomerulosclerosis After Pediatric Kidney Transplantation: A Retrospective Multicenter Study. Pediatr Transplant 2024; 28:e14809. [PMID: 38853135 DOI: 10.1111/petr.14809] [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: 10/10/2023] [Revised: 04/22/2024] [Accepted: 05/28/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Primary focal segmental glomerulosclerosis (FSGS) frequently recurs after kidney transplantation and is associated with poor graft survival. Patients who do not achieve remission (nonresponders) have an especially poor graft survival. However, the characteristics that may affect graft survival in nonresponders are unknown. This study aimed to determine the clinical characteristics associated with graft survival in nonresponders. METHODS We retrospectively collected the clinical records of patients with FSGS and an age at onset <16 years who experienced posttransplant recurrence of FSGS at six hospitals in Japan from 1993 to 2018. RESULTS Eight nonresponders with recurrent FSGS were enrolled in this study. The median time to recurrence after kidney transplantation was 1 day (interquartile range, 1-2 days). All patients received therapeutic plasma exchange and methylprednisolone pulse therapy. Rituximab was used as an add-on therapy in three patients. Five patients lost their graft within 2 years after kidney transplantation (rapid group). In contrast, three patients had much longer graft survival (nonrapid group). We compared the clinical characteristics of the rapid and nonrapid groups. Proteinuria tended to be lower in the nonrapid group at the third and subsequent months of therapy. The rapid group had persistent nephrotic syndrome. The rate of reduction in proteinuria was lower in the rapid group than in the nonrapid group. CONCLUSIONS Our study suggests that persistent nephrotic syndrome and a low rate of reduction in proteinuria may predict rapid progression to graft failure in nonresponders.
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Affiliation(s)
- Hideki Ban
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kenichiro Miura
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Taro Ando
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoko Shirai
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Naoto Kaneko
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kiyonobu Ishizuka
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
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2
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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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3
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Miura K, Ando T, Kanda S, Hashimoto T, Kaneko N, Ishizuka K, Hamada R, Hataya H, Hotta K, Gotoh Y, Nishiyama K, Hamasaki Y, Shishido S, Fujita N, Hattori M. Response to steroid and immunosuppressive therapies may predict post-transplant recurrence of steroid-resistant nephrotic syndrome. Pediatr Transplant 2022; 26:e14103. [PMID: 34309142 DOI: 10.1111/petr.14103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/05/2021] [Accepted: 07/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recurrence of SRNS is a major challenge in KT. Several clinical factors, including initial steroid sensitivity, have been associated with increased post-transplant SRNS recurrence risk. However, conflicting data have been reported, possibly due to the heterogeneous pathophysiology of SRNS and the lack of genetic testing of SRNS patients. Furthermore, the response to immunosuppressive therapies has not been evaluated. METHODS Seventy patients aged 1-15 years at SRNS onset who underwent KT between 2002 and 2018 were enrolled. Patients with secondary, familial, syndromic, and genetic forms of SRNS and those who were not treated with steroid were excluded. This study aimed to assess the risk factors for post-transplant recurrence, including treatment responses to initial steroid therapy and additional therapies with immunosuppressive agents, rituximab, plasmapheresis, and/or LDL-A. RESULTS Data from 36 kidney transplant recipients were analyzed. Twenty-two (61%) patients experienced post-transplant SRNS recurrence, while 14 patients did not. The proportion of patients who achieved complete or partial remission with initial steroid therapy and/or additional therapies with immunosuppressive agents, rituximab, plasmapheresis, and/or LDL-A was significantly higher in the SRNS recurrence group (19/22, 86%) than in the group without SRNS recurrence (6/14, 43%; p = .01). CONCLUSION This study suggests that the response to steroid treatment, other immunosuppressive agents, rituximab, plasmapheresis, and/or LDL-A may predict post-transplant SRNS recurrence.
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Affiliation(s)
- Kenichiro Miura
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Taro Ando
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shoichiro Kanda
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Taeko Hashimoto
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Naoto Kaneko
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kiyonobu Ishizuka
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshimitsu Gotoh
- Department of Pediatric Nephrology, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Kei Nishiyama
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuko Hamasaki
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Seiichiro Shishido
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Naoya Fujita
- Department of Nephrology, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
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4
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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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5
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Veissi ST, Smeets B, van Wijk JAE, van der Velden T, van den Heuvel LPWJ, Schreuder MF. Plasma exchange or immunoadsorption for recurrent focal segmental glomerulosclerosis: clear differences in vitro. Nephrol Dial Transplant 2022; 37:2293-2294. [PMID: 36083975 PMCID: PMC9585456 DOI: 10.1093/ndt/gfac255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Susan T Veissi
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud university medical center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Bart Smeets
- Department of Pathology, Radboud university medical center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Joanna A E van Wijk
- Department of Pediatric Nephrology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Thea van der Velden
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud university medical center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Lambertus P W J van den Heuvel
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud university medical center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud university medical center, Radboud Institute for Molecular Life Sciences Nijmegen, The Netherlands.,Department of Development and Regeneration, University Hospital Leuven, Leuven, Belgium
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud university medical center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
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6
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Praditau-krit S, Wongpraphairot S, Wetwittayakhlung P, Bejrananda T, Phongphithakchai A. A Rare Case Report of Postoperative Paraneoplastic Glomerulopathy in Kidney Transplant. EXP CLIN TRANSPLANT 2022; 20:867-870. [DOI: 10.6002/ect.2022.0164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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7
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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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8
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Ural Z, Helvacı Ö, Özbaş B, Güz G, Derici Ü. Unexpected Late Response to Ofatumumab in Adult Post-Transplantation Recurrent Focal Segmental Glomerulosclerosis, Case Report. Transplant Proc 2022; 54:1632-1635. [PMID: 35853766 DOI: 10.1016/j.transproceed.2022.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/12/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Idiopathic focal segmental glomerulosclerosis is an important cause of kidney failure in adults, which is associated with a high risk of disease recurrence after transplantation. Plasmapheresis, rituximab, immunoadsorption, and high-dose cyclosporine are used to treat post-transplant recurrent focal segmental glomerulosclerosis (rFSGS). However, the response rate is variable, and few options remain for unresponsive patients. CASE REPORT We present a 44-year-old man with an early post-transplant rFSGS. After peritransplant plasmapheresis, rituximab, and abatacept treatments failed, we employed ofatumumab. After 9 months without apparent benefit, we observed an unexpected partial remission thereafter, without severe side effects. Furthermore, remission has been sustained in 30-month follow-up. CONCLUSIONS We believe ofatumumab can be considered an alternative for patients with plasmapheresis and rituximab-resistant post-transplant rFSGS.
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Affiliation(s)
- Zeynep Ural
- Gazi University, Faculty of Medicine, Department of Nephrology, Ankara, Turkey.
| | - Özant Helvacı
- Gazi University, Faculty of Medicine, Department of Nephrology, Ankara, Turkey
| | - Burak Özbaş
- Erciyes University, Faculty of Medicine, Department of Endocrinology, Kayseri, Turkey
| | - Galip Güz
- Gazi University, Faculty of Medicine, Department of Nephrology, Ankara, Turkey
| | - Ülver Derici
- Gazi University, Faculty of Medicine, Department of Nephrology, Ankara, Turkey
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9
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Abstract
Organs for transplantation are a scarce resource. Markedly, the transplant community's primary challenge is the stark disparity between the number of patients awaiting deceased donor organ transplants and the rate at which organs become available. However, the allocation of a limited number of organs poses another constant challenge: maintaining an equilibrium between renal transplant utility and equity, that is, striking a balance between the utilitarian argument of medical efficiency and the principle of equity. In this comprehensive overview, the authors delve into the challenge of maintaining an acceptable balance between equity and efficiency and elaborate on some of the factors that might inform a decisionmaker's evaluation of the extent to which a given allocation scheme is efficient or equitable.
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10
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Baskın E, Avcı B, Gülleroğlu K, Akdur A, Moray G, Haberal M. Primary Focal Segmental Glomerulosclerosis Recurrence After Pediatric Renal Transplantation. EXP CLIN TRANSPLANT 2022; 20:55-60. [PMID: 35384808 DOI: 10.6002/ect.mesot2021.o24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Focal segmental glomerulosclerosis recurrence after renal transplant occurs frequently in pediatric patients and is associated with poor graft survival when patients reach adulthood. We investigated recurrence rates, recurrence risk factors, management strategies, and long-term graft function among pediatric renal transplant recipients with focal segmental glomerulosclerosis as primary disease. MATERIALS AND METHODS We retrospectively evaluated medical records of 34 pediatric patients with primary focal segmental glomerulosclerosis who had undergone renal transplant between 2004 and 2019 at our center. Focal segmental glomerulosclerosis recurrence was diagnosed by the presence of nephrotic range proteinuria after transplant and confirmed by graft biopsy. Preoperative prophylactic plasma exchange was administered to pediatric renal transplant recipients with primary focal segmental glomerulosclerosis. Plasma exchange was also used to treat focal segmental glomerulosclerosis recurrence, with rituximab added if the patient did not respond to plasma exchange. RESULTS All patients (male-to-female ratio of 19:15) in our group underwent renal transplant. Mean patient age at the time of transplant was 12.72 ± 5.46 years. Twenty-nine patients received living- related donor allografts (85.3%) and 5 received organs from deceased donors (14.7%). We identified focal segmental glomerulosclerosis recurrence in 5 recipients (14.7%). Time from focal segmental glomerulosclerosis diagnosis to end-stage renal disease and duration of dialysis were shorter in the recurrence group than in the nonrecurrence group (48.4 months [range, 2-90 mo] vs 65.1 months [range, 8-123 mo] and 1.41 ± 0.82 vs 3.18 ± 1.88 years, respectively; P < .05). Donor type and transplant age were similar in both groups. Of those with recurrence who had received plasma exchange and rituximab, 3 patients (75%) had complete remission and 1 patient (25%) had partial remission. CONCLUSIONS Prophylactic plasma exchange and the combined plasma exchange-rituximab regimen for treatment of focal segmental glomerulosclerosis recurrence resulted in low recurrence and good remission rates in our pediatric cohort.
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Affiliation(s)
- Esra Baskın
- From the Department of Pediatric Nephrology, Baskent University, Ankara, Turkey
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11
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Uffing A, Hullekes F, Hesselink DA, Mansur JB, Malvezzi P, de Vries AP, Seeger H, Manfro RC, Nissaisorakarn P, Wang AX, Reindl-Schwaighofer R, Sanchez-Russo L, Cravedi P, Riella LV, Berger SP. Long-term Apheresis in the Management of Patients with Recurrent Focal Segmental Glomerulosclerosis after Kidney Transplantation. Kidney Int Rep 2022; 7:1424-1427. [PMID: 35685308 PMCID: PMC9171618 DOI: 10.1016/j.ekir.2022.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/24/2022] [Accepted: 03/01/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Audrey Uffing
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frank Hullekes
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dennis A. Hesselink
- Department of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Juliana B. Mansur
- Division of Nephrology, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Paolo Malvezzi
- Service de Néphrologie, Dialyse, Aphérèses et Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Aiko P.J. de Vries
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, University of Leiden, Leiden, The Netherlands
| | - Harald Seeger
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Roberto C. Manfro
- Division of Nephrology, Hospital de clínicas de Porto Alegre/Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Pitchaphon Nissaisorakarn
- Division of Nephrology, Beth Israel Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Aileen X. Wang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Roman Reindl-Schwaighofer
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Luis Sanchez-Russo
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Paolo Cravedi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Leonardo V. Riella
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stefan P. Berger
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Correspondence: Stefan P. Berger, Department of Nephrology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
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12
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Kidney Transplantation for Focal Segmental Glomerulosclerosis: Can We Prevent Its Recurrence? Personal Experience and Literature Review. J Clin Med 2021; 11:jcm11010093. [PMID: 35011834 PMCID: PMC8745094 DOI: 10.3390/jcm11010093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Primary focal segmental glomerulosclerosis (FSGS) is associated with a high risk of recurrence after kidney transplantation with a major risk of graft loss despite preventive or curative treatments. Aim: to assess graft survival in FSGS kidney-transplant recipients and to compare those that had a relapse with those that had no relapse. Patients/Methods: we included 17 FSGS kidney-transplant recipients between January 2000 and January 2020, separated retrospectively into two groups (recurrences: n = 8 patients; no recurrences: n = 9 patients). FSGS recurrence was defined as having proteinuria of ≥3 g/g or urinary creatinine of ≥3 g/day. All patients received an induction therapy; maintenance immunosuppressive therapy at post-transplantation relied on tacrolimus/mycophenolate mofetil/steroids. In order to prevent or treat FSGS recurrence, patients received apheresis sessions plus rituximab. Results: FSGS recurrence rate was 47%. All patients that relapsed with a first graft also relapsed with subsequent grafts. Median time to recurrence was 3 (min: 1; max: 4745) days, despite rituximab/apheresis prophylaxis. Mean age was significantly lower in the relapsers (group 1) than in the non-relapsers (group 2); i.e., 47 ± 11 vs. 58 ± 9 years (p = 0.04). Time to progression to stage 5 chronic kidney disease (CKD) and young age at FSGS diagnosis were lower in group 1 compared to group 2; i.e., 5 (min: 1; max: 26) vs. 2 (min: 1; max: 26) years, and 16 (min: 4; max: 55) vs. 34 (min: 6; max 48) years, respectively. There was no difference between the two groups in terms of progression to CKD stage 5 on the native kidneys, averaging 7 years in both groups (p = 0.99). In group 1, seven patients received rituximab/apheresis prophylaxis, although this did not prevent the recurrence of FSGS. Conclusion: pretransplant prophylaxis with plasmapheresis/rituximab did not appear to reduce the risk of recurrence of primary FSGS on the graft, but could allow remission in the event of recurrence.
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13
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Al Shamsi HR, Shaheen I, Aziz D. Management of recurrent focal segmental glomerulosclerosis (FSGS) post renal transplantation. Transplant Rev (Orlando) 2021; 36:100675. [PMID: 34952298 DOI: 10.1016/j.trre.2021.100675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 12/05/2021] [Accepted: 12/13/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND One of the common GN causing ESKD is focal segmental glomerulosclerosis (FSGS). Recurrence of FSGS post-transplantation can lead to graft loss. Data on management either prophylactically or once recurrence occurs are limited. This review article aims to assess the effective management of patients with FSGS recurrence post-transplantation, looking mainly at recurrence post prophylactic treatment and remission in case of treatment post recurrence. METHODS Twenty-three studies were included using the search MeSH terms "FSGS" "recurrence" "adults" "transplantation" "treatment". Search engines used were Pubmed, clinical key, Scopus and Cochrane library. Inclusion criteria were articles covered adult patients with recurrent FSGS post renal transplantation, treatment with rituximab and plasmapheresis, and articles published from 2000 tt2021. Excluded articles were paediatric population, studies with no reported outcomes of the treatment of FSGS, and Patients who received stem cell transplantation or galactose therapy. RESULTS Prophylactic PP did not show a reduction in recurrence of FSGS in 2/3 studies. Prophylactic rituximab was shown to reduce recurrence of FSGS in one-study and case reports. Treatment of recurrent FSGS with PP showed responses ranging from 41% to 100%. Only one study did not show improvement with PP use as treatment having a 27% remission. Treatment with rituximab showed variable results, with reports showing remission ranging from 57% to 100%. Whereas other reports showing no response at all. PP prescription reporting was variable. One study suggested intensified PP regimen while in most other studies PP was guided by the response reflected by the reduction of proteinuria. DISCUSSION Reviewing the treatment of recurrent FSGS is crucial, as there no consensus on treating FSGS as the disease is not very common in the adult population. The evidence of different modalities is based on small cohort studies. This paper supports the use of PP and RTX as treatment of recurrent FSGS. CONCLUSIONS In conclusion, PP and RTX are the main modalities to treat recurrent FSGS with varying response rates. Prophylactic PP does not play a role in preventing recurrent FSGS. Prophylactic rituximab might play a role in preventing FSGS post-transplantation. PP and RTX, when used as a treatment, show variable response rates. Larger RCTs are needed to have a strong level of evidence to base our clinical management on.
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Fadel FI, Bazaraa HM, Abdel Mawla MA, Salah DM. Pediatric focal segmental glomerulosclerosis: favorable transplantation outcome with plasma exchange. Ital J Pediatr 2021; 47:236. [PMID: 34906202 PMCID: PMC8670281 DOI: 10.1186/s13052-021-01188-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/26/2021] [Indexed: 11/11/2022] Open
Abstract
Background Although kidney transplantation (KTX) is the treatment of choice for pediatric end stage kidney disease (ESKD); concerns for recurrence in cases of focal segmental glomerulosclerosis (FSGS) are still present. This study aimed to investigate the outcome of KTX in children with ESKD secondary to FSGS, with implementation of preemptive perioperative plasma exchange (PE) for non-genetically proven patients. Methods Forty FSGS pediatric kidney transplant recipients were studied. Of them: 12 patients (30%) had genetically proven NPHS2 mutations/familial and 28 (70%) were sporadic FSGS patients. All sporadic patients electively received 6 perioperative PE sessions. Patients with recurrence of proteinuria (n = 13; including 3 patients with genetic/familial and 10 patients with sporadic FSGS) were managed with PE and Rituximab (RTX). Kaplan-Meier curves were used to analyze graft and recurrence free survival data. Results The mean follow-up duration after KTX was 3.8 ± 2.86 years. Recurrence of proteinuria was encountered early postoperative in 11 patients (27.5%) and late (1.6 and 2.9 years after KTX) in 2 patients (5%). All patients with early recurrence achieved complete remission, while patients with late recurrence developed graft failure. Current serum creatinine and proteinuria levels were not different in patients received PE (n = 31) and patients did not PE (n = 9) (p = 0.308 and 0.287 respectively). Current serum creatinine and proteinuria levels in sporadic patients (n = 28) after prophylactic perioperative PE were not different from those of genetic/ familial patients (n = 12) (p = 0.303 and 0.144 respectively). Proteinuria was less in patients underwent native nephrectomy than others immediately postoperative and at assessment (p = 0.002 & 0.0031 respectively). One-year graft and patient survival was 93.8% with a mean 1-year serum creatinine of 0.67 ± 0.25 mg/dl. Three graft losses (7.5%) were due to chronic rejection 3.3, 3.75 and 4.17 years after KTX and 2 patients’ mortality (5%) occurred early postoperative (first 2 weeks). Conclusion FSGS transplanted children have favorable outcomes with perioperative PE for non-genetically proven cases. Early recurrence after KTX can be successfully managed with PE and RTX.
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Affiliation(s)
- Fatina I Fadel
- Department of Pediatrics, Pediatric Nephrology Unit, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hafez M Bazaraa
- Department of Pediatrics, Pediatric Nephrology Unit, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Doaa M Salah
- Department of Pediatrics, Pediatric Nephrology Unit, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
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15
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Moudgil A, Charnaya O. Re-transplantation after allograft loss due to recurrent focal segmental glomerulosclerosis: A glimmer of hope but miles to go. Pediatr Transplant 2021; 25:e14107. [PMID: 34331496 DOI: 10.1111/petr.14107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 07/24/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Asha Moudgil
- Department of Nephrology, Children's National Medical Center, Washington, DC, USA
| | - Olga Charnaya
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
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16
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Maniar A, Hooper DK, Sethna CB, Singer P, Traum A, Benoit E, Kotzen E, Verghese P, Garro R, Kamel M, Ranch D, Shih W, Jain NG, Al-Akash S. Re-transplantation in pediatric patients with failure of primary transplant due to recurrent focal segmental glomerulosclerosis: A pediatric nephrology research consortium study. Pediatr Transplant 2021; 25:e14085. [PMID: 34247442 PMCID: PMC8968923 DOI: 10.1111/petr.14085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/20/2021] [Accepted: 06/29/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Recurrent focal and segmental glomerulosclerosis (FSGS) in kidney transplant recipients is associated with lower graft survival and increased morbidity. There are limited data to guide the decision to re-transplant patients with transplant failure due to FSGS recurrence. We aimed to evaluate outcomes in patients re-transplanted after having initial graft failure due to recurrent FSGS and to study physician attitudes and practice patterns. METHODS Retrospective data from 10 centers were collected on 20 patients transplanted between January 1997 and September 2018. A survey was sent to nephrologist members of the Pediatric Nephrology Research Consortium. RESULTS Mean patient age (years) was 9.8 ± 4.8 at first transplant and 15.9 ± 4.9 at re-transplantation. Pre-transplant plasmapheresis was used in 1 (5.3%) primary transplant vs. 7 (38.9%) re-transplants (p = .03). Nephrotic syndrome recurred in 14 patients (70%) after re-transplantation and was severe in 21.1% vs. 64.7% after first transplant (p = .04). Graft survival was significantly higher in the second transplant (p .009) with 70% having functioning grafts at a median of 25.2 months. Thirty-one physicians from 21 centers completed the survey, 94% indicated they would re-transplant such patients, 44.4% preferred a minimum waiting period before re-transplantation, 36.4% preferred living donors, and 22.2% indicated having protocols for re-transplantation at their centers. CONCLUSIONS Consideration for re-transplantation is high among pediatric nephrologists. Pre-transplant plasmapheresis was more frequent in re-transplanted patients. Nephrotic syndrome recurrence was less severe, with better graft survival. More data and a larger population are necessary to further evaluate outcome determinants and best practices in this special population.
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Affiliation(s)
- Aesha Maniar
- Cohen Children’s Medical Center, New Hyde Park, NY, USA
| | - David K. Hooper
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Pamela Singer
- Cohen Children’s Medical Center, New Hyde Park, NY, USA
| | | | | | | | - Priya Verghese
- Ann and Robert H. Lurie Children’s Hospital, Chicago, IL, USA
| | - Rouba Garro
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Margaret Kamel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel Ranch
- University of Texas Health Science Center, San Antonio, TX, USA
| | - Weiwen Shih
- C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Namrata G. Jain
- Columbia University Irving Medical Center, New York, NY, USA
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17
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Mason AE, Saleem MA, Bierzynska A. A critical re-analysis of cases of post-transplantation recurrence in genetic nephrotic syndrome. Pediatr Nephrol 2021; 36:3757-3769. [PMID: 34031708 PMCID: PMC8497325 DOI: 10.1007/s00467-021-05134-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 04/29/2021] [Accepted: 05/12/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Genetic defects in podocyte proteins account for up to 30% of steroid-resistant nephrotic syndrome (SRNS) in the paediatric population. Most children with genetic SRNS are resistant to immunosuppression and at high risk of progression to stage 5 chronic kidney disease. Kidney transplantation is often the treatment of choice. The possibility of post-transplantation disease recurrence in genetic SRNS remains controversial, and poses fundamental questions about disease biology. METHODS We critically evaluated the published cases of post-transplantation recurrence in genetic patients, particularly testing 'mutations' against the most recent population variant databases, in order to clarify the diagnoses, and compare the clinical courses and responses to therapy. RESULTS Biallelic pathogenic variants in NPHS1 leading to a complete absence of nephrin were the most commonly reported and best understood instance of nephrotic syndrome occurring post-transplantation. This is an immune-mediated process driven by antibody production against the novel nephrin protein in the allograft. We also identified a number of plausible reported cases of post-transplantation recurrence involving pathogenic variants in NPHS2 (8 patients, biallelic), one in WT1 (monoallelic) and one in NUP93 (biallelic). However, the mechanism for recurrence in these cases remains unclear. Other instances of recurrence in genetic disease were difficult to interpret due to differing clinical criteria, inclusion of patients without true pathogenic variants or the influence of other factors on renal outcome. CONCLUSIONS Overall, post-transplantation recurrence remains very rare in patients with genetic SRNS. It appears to occur later after transplantation than in other patients and usually responds well to plasmapheresis with a good renal outcome.
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Affiliation(s)
- Anna E Mason
- Bristol Renal, Translational Health Sciences, Bristol Medical School, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol, BS1 3NY, UK
| | - Moin A Saleem
- Bristol Renal, Translational Health Sciences, Bristol Medical School, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol, BS1 3NY, UK.
| | - Agnieszka Bierzynska
- Bristol Renal, Translational Health Sciences, Bristol Medical School, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol, BS1 3NY, UK
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18
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Uffing A, Hullekes F, Riella LV, Hogan JJ. Recurrent Glomerular Disease after Kidney Transplantation: Diagnostic and Management Dilemmas. Clin J Am Soc Nephrol 2021; 16:1730-1742. [PMID: 34686531 PMCID: PMC8729409 DOI: 10.2215/cjn.00280121] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Recurrent glomerular disease after kidney transplant remains an important cause of allograft failure. Many of the different entities post-transplant still suffer from incomplete knowledge on pathophysiology, and therefore lack targeted and effective therapies. In this review, we focus on specific clinical dilemmas encountered by physicians in managing recurrent glomerular disease by highlighting new insights into the understanding and treatment of post-transplant focal segmental glomerulosclerosis, membranous nephropathy, atypical hemolytic uremic syndrome, C3 glomerulopathy, amyloid light-chain (AL) amyloidosis, and IgA nephropathy.
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Affiliation(s)
- Audrey Uffing
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Hullekes
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V. Riella
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan J. Hogan
- Division of Renal Electrolyte and Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Zhao Y, Zhang H, Wang H, Ye M, Jin X. Role of formin INF2 in human diseases. Mol Biol Rep 2021; 49:735-746. [PMID: 34698992 DOI: 10.1007/s11033-021-06869-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/21/2021] [Indexed: 01/08/2023]
Abstract
Formin proteins catalyze actin nucleation and microfilament polymerization. Inverted formin 2 (INF2) is an atypical diaphanous-related formin characterized by polymerization and depolymerization of actin. Accumulating evidence showed that INF2 is associated with kidney disease focal segmental glomerulosclerosis and cancers, such as colorectal and thyroid cancer where it functions as a tumor suppressor, glioblastoma, breast, prostate, and gastric cancer, via its oncogenic function. However, studies on the underlying molecular mechanisms of the different roles of INF2 in diverse cancers are limited. This review comprehensively describes the structure, biochemical features, and primary pathogenic mutations of INF2.
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Affiliation(s)
- Yiting Zhao
- Department of Hepato-Biliary-Pancreatic Surgery, The Affiliated Ningbo Medical Center of LiHuiLi Hospital of Medical School of Ningbo University, Ningbo, 315048, China.,The Affiliated Hospital of Medical School, Ningbo University, Ningbo, 315020, China
| | - Hui Zhang
- Department of Biochemistry and Molecular Biology, and Zhejiang Key Laboratory of Pathophysiology, Medical School of Ningbo University, Ningbo, 315211, China.,The Affiliated Hospital of Medical School, Ningbo University, Ningbo, 315020, China
| | - Haibiao Wang
- Department of Hepato-Biliary-Pancreatic Surgery, The Affiliated Ningbo Medical Center of LiHuiLi Hospital of Medical School of Ningbo University, Ningbo, 315048, China. .,Department of Biochemistry and Molecular Biology, and Zhejiang Key Laboratory of Pathophysiology, Medical School of Ningbo University, Ningbo, 315211, China.
| | - Meng Ye
- Department of Biochemistry and Molecular Biology, and Zhejiang Key Laboratory of Pathophysiology, Medical School of Ningbo University, Ningbo, 315211, China. .,The Affiliated Hospital of Medical School, Ningbo University, Ningbo, 315020, China.
| | - Xiaofeng Jin
- Department of Biochemistry and Molecular Biology, and Zhejiang Key Laboratory of Pathophysiology, Medical School of Ningbo University, Ningbo, 315211, China. .,The Affiliated Hospital of Medical School, Ningbo University, Ningbo, 315020, China.
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20
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Theophilus UI, John JR, Ihab S, Ahmed H. Recurrent Focal Segmental Glomerulosclerosis After Kidney Transplantation in African Americans: Review of the Current Evidence. EXP CLIN TRANSPLANT 2021; 19:1245-1256. [PMID: 34269655 DOI: 10.6002/ect.2020.0542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES In many countries of sub-Saharan Africa, the most common causes of end-stage kidney disease are hypertension, chronic glomerulonephritis, and diabetes mellitus. So far, literature on recurrent focal segmental glomerulosclerosis in sub-Saharan African populations is limited. With the intention of providing guidance for best practices in sub-Saharan Africa, we reviewed available evidence for African Americans, a population with a similar genetic background. We chose this population as a pseudo-population to show how similar genetic backgrounds can predict disease occurrence in similar populations residing in different continents. MATERIALS AND METHODS Our extended PubMed and Scopus literature search used these key words: "focal segmental glomerulosclerosis in African Americans" (search 1), "recurrent focal segmental glomerulosclerosis after kidney transplantation" (search 2), "risk factors for recurrent focal segmental glomerulosclerosis" (search 3); and "APOL1 gene and kidney transplantation" (search 4). RESULTS/CONCLUSIONS Search 1 yielded 4 articles, search 2 yielded 44 articles, search 3 yielded 6 articles, and search 4 yielded 8 articles. African Americans were shown to be disproportionately predisposed to endstage kidney disease, traceable to focal segmental glomerulosclerosis (the most common cause of glomerulonephritis leading to end-stage kidney disease). Apolipoprotein L1 presence in 22% of African Americans explained the odds ratio of 17 in developing focal segmental glomerulosclerosis and 8 times lifetime risk of end-stage kidney disease. Focal segmental glomerulosclerosis recurred in 30% of kidney transplant recipients; risk factors included young age, rapid progression to end-stage kidney disease, and White race recipient. Circulating permeability factors played a central role in primary and recurrent focal segmental glomerulosclerosis. For recurrent cases, transplant biopsy has remained the gold standard for diagnosis, with treatment involving a multi-modal approach, often resulting in partial or complete remission of proteinuria; allograft loss can occur if treatment is not successful. More randomized clinical trials are needed to chart the way forward for prolonged allograft function.
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Affiliation(s)
- Umeizudike I Theophilus
- From the Department of Medicine, Lagos State University Teaching Hospital, Ikeja, Lagos State, Nigeria
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21
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A Specific Tubular ApoA-I Distribution Is Associated to FSGS Recurrence after Kidney Transplantation. J Clin Med 2021; 10:jcm10102174. [PMID: 34069888 PMCID: PMC8157584 DOI: 10.3390/jcm10102174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/14/2021] [Indexed: 01/27/2023] Open
Abstract
A major complication of primary focal segmental glomerulosclerosis (FSGS) is its recurrence after kidney transplantation that happens in 30 to 40% of the patients. The diagnosis of these relapses is not always easy as the histological lesions are not highly specific and appear after the proteinuria increase. Currently, there are no accurate biomarkers to detect FSGS recurrence. Our group identified a modified form of Apolipoprotein A-I (ApoA-I), named ApoA-Ib, specifically present in the urine of recurrent FSGS patients after kidney transplantation. Aberrant forms of ApoA-I have also been described in the urine of native primary FSGS patients; this feature has been associated with prominent staining of ApoA-I at the apical membrane of the tubular cells. In this study, we aim to analyze the ApoA-I distribution in kidney allograft biopsies of recurrent FSGS patients. We detected ApoA-I by immunohistochemistry in kidney allograft biopsies of patients with FSGS relapse after kidney transplantation and in kidney allograft biopsies of patients with a disease different from FSGS in the native kidney (non-FSGS). In recurrent FSGS patients, ApoA-I was prominently localized at the brush border of the tubular cells, while in the non-FSGS patients, ApoA-I was found along the cytoplasm of the tubular cells. The localization of ApoA-I at the brush border of the tubular cells is a specific feature of primary FSGS in relapse. This suggests that ApoA-I staining in kidney biopsies, coupled with ApoA-Ib measurement in urine, could be used as a diagnostic tool of primary FSGS relapse after kidney transplantation due to its highly specific tubular distribution.
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22
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Usui J, Yamagata K, Nagata M, Shimizu A, Takeda A, Sugiyama H, Sato H, Yokoyama H. Nationwide Survey of Post-Transplant Glomerular Diseases, Based on the Japan Renal Biopsy Registry (J-RBR). Ann Transplant 2021; 26:e931873. [PMID: 33986240 PMCID: PMC8130503 DOI: 10.12659/aot.931873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Nationwide data on allograft kidney biopsies have been limited in number, in contrast to the large amount of accumulated data on native kidney biopsies. In this context, we have surveyed transplant biopsy data based on the nationwide database, the Japan Renal Biopsy Registry (J-RBR). Material/Methods A total of 2430 transplant biopsy cases were registered in the web-based J-RBR from January 2007 to January 2018. We categorized the entries regarding both the purpose of the biopsy and pathological diagnosis, and confirmed transplant glomerular diseases based on the clinical and pathological diagnosis. Results Of the 2430 total transplant biopsy cases, 637 cases, including 9 cases of baseline biopsy, 216 cases of protocol biopsy, and 232 cases of episode biopsy, had a pathological diagnosis, including glomerular diseases, rejection, calcineurin inhibitor nephropathy, and interstitial fibrosis and tubular atrophy. Of these, 127 cases presented with glomerular disease, including 8 cases of baseline biopsy, 23 of protocol biopsy, 59 of episode biopsy, and 37 of unknown purpose). A total of 127 biopsies with glomerular disease revealed a high prevalence of immunoglobulin A nephropathy (n=38, 29.9%), followed by mesangial proliferative glomerulonephritis (n=29, 22.8%) and focal segmental glomerulosclerosis (n=8, 6.3%) when focused on protocol and episode biopsies. Conclusions The nationwide transplant biopsy database demonstrated the pathological characteristics of 637 cases, including 127 cases of post-transplant glomerular disease. The protocol and episode biopsies included high prevalence rates of IgAN, followed by FSGS.
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Affiliation(s)
- Joichi Usui
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Michio Nagata
- Department of Pathology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Asami Takeda
- Kidney Disease Center, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Sato
- Clinical Pharmacology and Therapeutics, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Miyagi, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, Uchinada, Ishikawa, Japan
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23
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Al-Jehani MH, Al-Husayni F, Aljabri A, AlMaghraby HQ, Banamah TA. Cyclophosphamide as a Treatment for Focal Segmental Glomerular Sclerosis Recurrence in a Kidney Transplant Patient. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929097. [PMID: 33539328 PMCID: PMC7871296 DOI: 10.12659/ajcr.929097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Female, 24-year-old Final Diagnosis: Focal segmental glomerulosclerosis Symptoms: Facia • lower extremity edema Medication: — Clinical Procedure: — Specialty: Nephrology
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Affiliation(s)
- Mariann H Al-Jehani
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Faisal Al-Husayni
- Department of Internal Medicine, National Guard Hospital, King Abdulaziz Medical City, Jeddah, Saudi Arabia.,Department of Internal Medicine, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdullah Aljabri
- Department of Internal Medicine, National Guard Hospital, King Abdulaziz Medical City, Jeddah, Saudi Arabia.,Department of Internal Medicine, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Hatim Qasim AlMaghraby
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,Department of Pathology, National Guard Hospital, King Abdulaziz Medical City, Jeddah, Saudi Arabia.,Department of Pathology, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Turki A Banamah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,Department of Nephrology, National Guard Hospital, Jeddah, Saudi Arabia.,Department of Nephrology, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
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24
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Ozeki T, Maruyama S, Imasawa T, Kawaguchi T, Kitamura H, Kadomura M, Katafuchi R, Oka K, Yokoyama H, Sugiyama H, Sato H. Clinical manifestations of focal segmental glomerulosclerosis in Japan from the Japan Renal Biopsy Registry: age stratification and comparison with minimal change disease. Sci Rep 2021; 11:2602. [PMID: 33510182 PMCID: PMC7844271 DOI: 10.1038/s41598-020-80931-9] [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: 08/27/2020] [Accepted: 12/18/2020] [Indexed: 11/12/2022] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a serious condition leading to kidney failure. We aimed to investigate the clinical characteristics of FSGS and its differences compared with minimal change disease (MCD) using cross-sectional data from the Japan Renal Biopsy Registry. In Analysis 1, primary FSGS (n = 996) were stratified by age into three groups: pediatric (< 18 years), adult (18–64 years), and elderly (≥ 65 years), and clinical characteristics were compared. Clinical diagnosis of nephrotic syndrome (NS) was given to 73.5% (97/132) of the pediatric, 41.2% (256/622) of the adult, and 65.7% (159/242) of the elderly group. In Analysis 2, primary FSGS (n = 306) and MCD (n = 1303) whose clinical diagnosis was nephrotic syndrome (NS) and laboratory data were consistent with NS, were enrolled. Logistic regression analysis was conducted to elucidate the variables which can distinguish FSGS from MCD. On multivariable analysis, higher systolic blood pressure, higher serum albumin, lower eGFR, and presence of hematuria associated with FSGS. In Japanese nationwide registry, primary FSGS patients aged 18–64 years showed lower rate of NS than those in other ages. Among primary nephrotic cases, FSGS showed distinct clinical features from MCD.
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Affiliation(s)
- Takaya Ozeki
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Toshiyuki Imasawa
- Department of Nephrology, National Hospital Organization Chibahigashi National Hospital, Chiba, Japan
| | - Takehiko Kawaguchi
- Department of Nephrology, National Hospital Organization Chibahigashi National Hospital, Chiba, Japan
| | - Hiroshi Kitamura
- Department of Pathology, National Hospital Organization Chibahigashi National Hospital, Chiba, Japan
| | - Moritoshi Kadomura
- Department of Nephrology, National Hospital Organization Chibahigashi National Hospital, Chiba, Japan
| | - Ritsuko Katafuchi
- Department of Nephrology, Medical Corporation Houshikai Kano Hospital, Fukuoka, Japan.,Kidney Unit, National Hospital Organization Fukuoka Higashi Medical Center, Fukuoka, Japan
| | - Kazumasa Oka
- Department of Pathology, Hyogo Prefectural Nishinomiya Hospital, Hyogo, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, Ishikawa, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Sato
- Department of Internal Medicine, Sendai Hospital of East Japan Railway Company, Sendai, Japan
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Vallianou K, Marinaki S, Skalioti C, Lionaki S, Darema M, Melexopoulou C, Boletis I. Therapeutic Options for Recurrence of Primary Focal Segmental Glomerulonephritis (FSGS) in the Renal Allograft: Single-Center Experience. J Clin Med 2021; 10:jcm10030373. [PMID: 33498160 PMCID: PMC7863737 DOI: 10.3390/jcm10030373] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/09/2021] [Accepted: 01/14/2021] [Indexed: 12/12/2022] Open
Abstract
Focal Segmental Glomerulosclerosis (FSGS) recurrence after kidney transplantation (KTx) is relatively frequent and is associated with poor graft survival. The aim of this study was to investigate which management strategies were associated with better outcomes in our cohort of KTx recipients with primary FSGS. We retrospectively collected data on patients with primary FSGS who received a KTx between 1993 and 2019. A history of biopsy proven FSGS in native kidneys and new onset of significant proteinuria early post-KTx led to the diagnosis of recurrence, which was confirmed by graft biopsy. From 1993 to 2019 we performed 46 KTxs in patients with primary FSGS. We identified 26 episodes of recurrence in 25 patients, 67% of them occurring in males. They were younger at the time of KTx (33.8 vs. 41.1 years old, p = 0.067) and had progressed to end stage renal disease (ESRD) faster after FSGS diagnosis (61.4 vs. 111.2 months, p = 0.038), while they were less likely to have received prophylactic plasmapheresis (61.5% vs. 90%, p = 0.029). 76.7% of recurrences were found early, after a median of 0.5 months (IQR 0.1-1) with a median proteinuria was 8.5 (IQR 4.9-11.9) g/day. All patients with recurrence were treated with plasmapheresis, while 8 (30.7%) additionally received rituximab, 1 (3.8%) abatacept, and 4 (15.4%) ACTH. 7 (27%) patients experienced complete and 11 (42.3%) partial remission after a mean time of 3 (±1.79) and 4.4 (±2.25) months, respectively. Prognosis was worse for patients who experienced a recurrence. Eleven (42.3%) patients lost their graft from FSGS in a median time of 33 (IQR 17.5-43.3) months. In this series of patients, primary FSGS recurred frequently after KTx. Prophylacic plasmapheresis was shown efficacious in avoiding FSGS recurrence, while timely diagnosis and plasmapheresis-based regimens induced remission in more than half of the patients.
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Factors Influencing Disease Recurrence and Graft Survival in Patients who Developed End-Stage Renal Disease Due to Focal Segmental Glomerulosclerosis and Underwent Renal Transplantation. Int Surg 2021. [DOI: 10.9738/intsurg-d-15-00154.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim
The aim of our study was to determine the factors effecting disease recurrence and graft survival in patients who developed end-stage renal disease (ESRD) due to focal segmental glomerulosclerosis (FSGS) and underwent renal transplantation (Rtx).
Methods
A total of 37 patients with FSGS (female/male: 10/27) who underwent Rtx in our transplant center between 2001 and 2014 were included in the study. The patients were diagnosed with FSGS by biopsy. Comparative analyses were performed in order to determine the factors effecting disease recurrence and graft survival. Plasmapheresis was performed with 40 mL/kg plasma. The diagnosis of the recurrence of FSGS and the acute rejections were also confirmed by biopsy.
Results
Statistical analyses revealed that, recurrence rates were higher in Rtx recipients from deceased donor [deceased donor versus living donor, 2 (50.0%) versus 3 (9.1%), P = 0.024]. However, no correlation was found between recurrence and renal replacement treatment (RRT) methods, duration of RRT, preoperative or postoperative prophylactic plasmapheresis, the presence of preoperative nephrotic proteinuria, donor's or recipient's age or gender, kinship with donor, time interval between development of FSGS and ESRD, or performing native nephrectomy. Graft survival rates were higher in Rtx patients that were transplanted from living donor, first-degree relatives, and in patients without recurrence.
Conclusion
In countries where organ donation is insufficient, living donors can be used with a low risk of recurrence for Rtx candidates with FSGS. Also, grafts from living donors, particularly from first-degree relatives, have higher survival rates.
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Infante B, Rossini M, Leo S, Troise D, Netti GS, Ranieri E, Gesualdo L, Castellano G, Stallone G. Recurrent Glomerulonephritis after Renal Transplantation: The Clinical Problem. Int J Mol Sci 2020; 21:ijms21175954. [PMID: 32824988 PMCID: PMC7504691 DOI: 10.3390/ijms21175954] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/30/2020] [Accepted: 08/17/2020] [Indexed: 12/22/2022] Open
Abstract
Glomerulonephritis (GN) continues to be one of the main causes of end-stage kidney disease (ESKD) with an incidence rating from 10.5% to 38.2%. Therefore, recurrent GN, previously considered to be a minor contributor to graft loss, is the third most common cause of graft failure 10 years after renal transplantation. However, the incidence, pathogenesis, and natural course of recurrences are still not completely understood. This review focuses on the most frequent diseases that recur after renal transplantation, analyzing rate of recurrence, epidemiology and risk factors, pathogenesis and bimolecular mechanisms, clinical presentation, diagnosis, and therapy, taking into consideration the limited data available in the literature. First of all, the risk for recurrence depends on the type of glomerulonephritis. For example, recipient patients with anti-glomerular basement membrane (GBM) disease present recurrence rarely, but often exhibit rapid graft loss. On the other hand, recipient patients with C3 glomerulonephritis present recurrence in more than 50% of cases, although the disease is generally slowly progressive. It should not be forgotten that every condition that can lead to chronic graft dysfunction should be considered in the differential diagnosis of recurrence. Therefore, a complete workup of renal biopsy, including light, immunofluorescence and electron microscopy study, is essential to provide the diagnosis, excluding alternative diagnosis that may require different treatment. We will examine in detail the biomolecular mechanisms of both native and transplanted kidney diseases, monitoring the risk of recurrence and optimizing the available treatment options.
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Affiliation(s)
- Barbara Infante
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Michele Rossini
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Serena Leo
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Dario Troise
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Giuseppe Stefano Netti
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Elena Ranieri
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy;
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
- Correspondence: ; Tel.: +39-0881732610; Fax: +39-0881736001
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
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Jacobs-Cachá C, Vergara A, García-Carro C, Agraz I, Toapanta-Gaibor N, Ariceta G, Moreso F, Serón D, López-Hellín J, Soler MJ. Challenges in primary focal segmental glomerulosclerosis diagnosis: from the diagnostic algorithm to novel biomarkers. Clin Kidney J 2020; 14:482-491. [PMID: 33623672 PMCID: PMC7886539 DOI: 10.1093/ckj/sfaa110] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 05/04/2020] [Indexed: 12/11/2022] Open
Abstract
Primary or idiopathic focal segmental glomerulosclerosis (FSGS) is a kidney entity that involves the podocytes, leading to heavy proteinuria and in many cases progresses to end-stage renal disease. Idiopathic FSGS has a bad prognosis, as it involves young individuals who, in a considerably high proportion (∼15%), are resistant to corticosteroids and other immunosuppressive treatments as well. Moreover, the disease recurs in 30–50% of patients after kidney transplantation, leading to graft function impairment. It is suspected that this relapsing disease is caused by a circulating factor(s) that would permeabilize the glomerular filtration barrier. However, the exact pathologic mechanism is an unsettled issue. Besides its poor outcome, a major concern of primary FSGS is the complexity to confirm the diagnosis, as it can be confused with other variants or secondary forms of FSGS and also with other glomerular diseases, such as minimal change disease. New efforts to optimize the diagnostic approach are arising to improve knowledge in well-defined primary FSGS cohorts of patients. Follow-up of properly classified primary FSGS patients will allow risk stratification for predicting the response to different treatments. In this review we will focus on the diagnostic algorithm used in idiopathic FSGS both in native kidneys and in disease recurrence after kidney transplantation. We will emphasize those potential confusing factors as well as their detection and prevention. In addition, we will also provide an overview of ongoing studies that recruit large cohorts of glomerulopathy patients (Nephrotic Syndrome Study Network and Cure Glomerulonephropathy, among others) and the experimental studies performed to find novel reliable biomarkers to detect primary FSGS.
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Affiliation(s)
- Conxita Jacobs-Cachá
- Nephrology Research Group, Vall d'hebrón Institut de Recerca (VHIR), Barcelona, Spain.,Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain.,Red de Investigaciones Renales (RedInRen), Madrid, Spain
| | - Ander Vergara
- Nephrology Research Group, Vall d'hebrón Institut de Recerca (VHIR), Barcelona, Spain.,Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Clara García-Carro
- Nephrology Research Group, Vall d'hebrón Institut de Recerca (VHIR), Barcelona, Spain.,Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain.,Red de Investigaciones Renales (RedInRen), Madrid, Spain
| | - Irene Agraz
- Nephrology Research Group, Vall d'hebrón Institut de Recerca (VHIR), Barcelona, Spain.,Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain.,Red de Investigaciones Renales (RedInRen), Madrid, Spain
| | - Nestor Toapanta-Gaibor
- Nephrology Research Group, Vall d'hebrón Institut de Recerca (VHIR), Barcelona, Spain.,Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Gema Ariceta
- Red de Investigaciones Renales (RedInRen), Madrid, Spain.,Department of Paediatric Nephrology, Hospital Universitari Vall d'Hebron. Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Francesc Moreso
- Nephrology Research Group, Vall d'hebrón Institut de Recerca (VHIR), Barcelona, Spain.,Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain.,Red de Investigaciones Renales (RedInRen), Madrid, Spain
| | - Daniel Serón
- Nephrology Research Group, Vall d'hebrón Institut de Recerca (VHIR), Barcelona, Spain.,Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain.,Red de Investigaciones Renales (RedInRen), Madrid, Spain
| | - Joan López-Hellín
- Red de Investigaciones Renales (RedInRen), Madrid, Spain.,Department of Biochemistry, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain.,Biochemistry Research Group, Vall d'hebrón Institut de Recerca (VHIR), Barcelona, Spain
| | - Maria José Soler
- Nephrology Research Group, Vall d'hebrón Institut de Recerca (VHIR), Barcelona, Spain.,Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain.,Red de Investigaciones Renales (RedInRen), Madrid, Spain
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Bernard J, Lalieve F, Sarlat J, Perrin J, Dehoux L, Boyer O, Godron-Dubrasquet A, Harambat J, Decramer S, Caillez M, Bruel A, Allain-Launay E, Dantal J, Roussey G. Ofatumumab treatment for nephrotic syndrome recurrence after pediatric renal transplantation. Pediatr Nephrol 2020; 35:1499-1506. [PMID: 32306087 DOI: 10.1007/s00467-020-04567-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Relapsing nephrotic syndrome (NS) after transplantation can be a challenge to treat. The result of the consequent long-lasting proteinuria is the loss of the graft. Disease recurrence after renal transplantation occurs in around half of cases, and the efficacy of therapeutic strategies is often limited. Recently, ofatumumab, a second-generation and fully human anti-CD20 monoclonal antibody, has been shown to be effective in severe situations. METHODS We retrospectively collected data from the medical records of children with recurrence of NS after renal transplantation treated with ofatumumab in France, after failure of previous treatments. RESULTS Six patients were included in this study in five centers with a median duration of follow-up of 10.5 months. Two different ofatumumab regimens were administered. The primary outcome was proteinuria at 6 months after the last dose of ofatumumab. No patient achieved a complete remission, 3/6 had a partial remission, and 3/6 had no response to ofatumumab. Four patients exhibited a minor allergic reaction with the first infusion. One patient died of infection, as a consequence of multiple factors. No malignancies were observed; however, the time of follow-up was not sufficient to see such disease. CONCLUSIONS Altogether, these results suggest ofatumumab has a poor efficacy in treating recurrence of NS after renal transplantation. However, it could be discussed in multidrug-resistant refractory NS, but infectious complications and overimmunosuppression have to be balanced. There is a need for further studies to confirm these findings and safety and to determine a standardized protocol in this indication.
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Affiliation(s)
- Josselin Bernard
- Pediatric Department, University Hospital of Nantes, Nantes, France.
- Service de Maladies Chroniques de l'enfant, Hôpital femme-enfants-adolescent, CHU Nantes, 7, quai Moncousu, 44093, Cedex Nantes, France.
| | - Fanny Lalieve
- Pediatric Department, University Hospital of Bordeaux, Bordeaux, France
| | - Julie Sarlat
- Pediatric Department, University Hospital of Toulouse, Toulouse, France
| | - Justine Perrin
- Pediatric Department, University Hospital of Marseille, Marseille, France
| | - Laurene Dehoux
- Pediatric Nephrology Department, University Hospital of Necker Enfants Malades, APHP, Paris, France
| | - Olivia Boyer
- Pediatric Nephrology Department, University Hospital of Necker Enfants Malades, APHP, Paris, France
| | | | - Jerome Harambat
- Pediatric Department, University Hospital of Bordeaux, Bordeaux, France
| | - Stephane Decramer
- Pediatric Department, University Hospital of Toulouse, Toulouse, France
| | - Mathilde Caillez
- Pediatric Department, University Hospital of Marseille, Marseille, France
| | - Alexandra Bruel
- Pediatric Department, University Hospital of Nantes, Nantes, France
- Service de Maladies Chroniques de l'enfant, Hôpital femme-enfants-adolescent, CHU Nantes, 7, quai Moncousu, 44093, Cedex Nantes, France
| | - Emma Allain-Launay
- Pediatric Department, University Hospital of Nantes, Nantes, France
- Service de Maladies Chroniques de l'enfant, Hôpital femme-enfants-adolescent, CHU Nantes, 7, quai Moncousu, 44093, Cedex Nantes, France
| | - Jacques Dantal
- Nephrology and Immunology Department, University Hospital of Nantes, Nantes, France
| | - Gwenaëlle Roussey
- Pediatric Department, University Hospital of Nantes, Nantes, France
- Service de Maladies Chroniques de l'enfant, Hôpital femme-enfants-adolescent, CHU Nantes, 7, quai Moncousu, 44093, Cedex Nantes, France
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30
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Shabaka A, Tato Ribera A, Fernández-Juárez G. Focal Segmental Glomerulosclerosis: State-of-the-Art and Clinical Perspective. Nephron Clin Pract 2020; 144:413-427. [PMID: 32721952 DOI: 10.1159/000508099] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/20/2020] [Indexed: 12/18/2022] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a histological pattern of glomerular injury, rather than a single disease, that is caused by diverse clinicopathological entities with different mechanisms of injury with the podocyte as the principal target of lesion, leading to the characteristic sclerotic lesions in parts (i.e., focal) of some (i.e., segmental) glomeruli. The lesion of FSGS has shown an increasing prevalence over the past few decades and is considered the most common glomerular cause leading to ESKD. Primary FSGS, which usually presents with nephrotic syndrome, is thought to be caused by circulating permeability factors that have a main role in podocyte foot process effacement. Secondary forms of FSGS include maladaptive FSGS secondary to glomerular hyperfiltration such as in obesity or in cases of loss in nephron mass, virus-associated FSGS, and drug-associated FSGS that can result in direct podocyte injury. Genetic FSGS is increasingly been recognized and a careful evaluation of patients with atypical primary or secondary FSGS should be performed to exclude genetic causes. Unlike primary FSGS, secondary and genetic forms of FSGS do not respond to immunosuppression and tend not to recur after kidney transplantation. Distinguishing primary FSGS from secondary and genetic causes has a prognostic significance and is crucial for an appropriate management. In this review, we examine the pathogenesis, clinical approach to distinguish between the different causes, and current recommendations in the management of FSGS.
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Affiliation(s)
- Amir Shabaka
- Nephrology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Ana Tato Ribera
- Nephrology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain
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31
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Abuzeineh M, Aala A, Alasfar S, Alachkar N. Angiotensin II receptor 1 antibodies associate with post-transplant focal segmental glomerulosclerosis and proteinuria. BMC Nephrol 2020; 21:253. [PMID: 32615995 PMCID: PMC7331243 DOI: 10.1186/s12882-020-01910-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/25/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Angiotensin II type 1 receptors (AT1Rs) are expressed on podocytes, endothelial and other cells, and play an essential role in the maintenance of podocyte function and vascular homeostasis. The presence of AT1R antibodies (AT1R-Abs) leads to activation of these receptors resulting in podocyte injury and endothelial cell dysfunction. We assessed the correlation between AT1R-Abs and the risk of post-transplant FSGS. METHODS This is a retrospective study, which included all kidney transplant recipients with positive AT1R-Abs (≥ 9 units/ml), who were transplanted and followed at our center between 2006 and 2016. We assessed the development of biopsy proven FSGS and proteinuria by urine protein to creatinine ratio of ≥1 g/g and reviewed short and long term outcomes. RESULTS We identified 100 patients with positive AT1R-Abs at the time of kidney transplant biopsy or proteinuria. 49% recipients (FSGS group) had biopsy-proven FSGS and/or proteinuria and 51% did not (non-FSGS group). Pre-transplant hypertension was present in 89% of the FSGS group compared to 72% in the non-FSGS group, p = 0.027. Of the FSGS group, 43% were on angiotensin converting enzyme inhibitors or angiotensin receptor blockers prior to transplantation, compared to 25.5% in the non-FSGS group, p = 0.06. Primary idiopathic FSGS was the cause of ESRD in 20% of the FSGS group, compared to 6% in the non-FSGS group, p = 0.03. The allograft loss was significantly higher in the FSGS group 63% compared to 39% in non-FSGS. Odds ratio and 95% confidence interval were 2.66 (1.18-5.99), p = 0.017. CONCLUSIONS Our data suggest a potential association between AT1R-Abs and post-transplant FSGS leading to worse allograft outcome. Therefore, AT1R-Abs may be considered biomarkers for post-transplant FSGS.
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Affiliation(s)
- Mohammad Abuzeineh
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Carnegie 344B, Baltimore, MD, 21287, USA
| | - Amtul Aala
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sami Alasfar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Carnegie 344B, Baltimore, MD, 21287, USA
| | - Nada Alachkar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Carnegie 344B, Baltimore, MD, 21287, USA.
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Jyothish M, Berry M, Neil D. Outcomes of renal transplantation in adult patients with primary focal segmental glomerulosclerosis: a single-centre experience over 5 decades. Clin Med (Lond) 2020; 20:s111. [PMID: 32409414 DOI: 10.7861/clinmed.20-2-s111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Miriam Berry
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Desley Neil
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Zhang X, Herr F, Vernochet A, Lorenzo HK, Beaudreuil S, Dürrbach A. CASK, the Soluble Glomerular Permeability Factor, Is Secreted by Macrophages in Patients With Recurrent Focal and Segmental Glomerulo-Sclerosis. Front Immunol 2020; 11:875. [PMID: 32477353 PMCID: PMC7235163 DOI: 10.3389/fimmu.2020.00875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/16/2020] [Indexed: 01/17/2023] Open
Abstract
Introduction: Focal and segmental glomerulosclerosis (FSGS) is a frequent form of glomerulonephritis that may be caused by a soluble permeability factor and regulated by the immune system. We previously described a soluble form of calcium/calmodulin-dependent serine/threonine kinase (CASK) acting as a permeability factor in patients with recurrent FSGS (rFSGS). Here, we aimed to identify the immune cells associated with CASK secretion in patients with rFSGS. Methods: FACS, western blotting and immunoprecipitation were performed to detect CASK in peripheral blood mononuclear cells, including CD3+, CD20+, and CD14+subsets, from patients with rFSGS, healthy donors, transplant patients and patients with nephrotic syndrome due to diabetes mellitus, and in KHM2 cells. Results: CASK was produced mostly by monocytes in patients with rFSGS but not by T or B lymphocytes. It was not detectein cells from control patients. CASK was also produced and secreted by M2 polarized macrophages and KMH2 cells, but not by M1 polarized macrophages. CASK secretion was not not inhibited by brefeldin A, suggesting an absence of classical secretion pathway involvement. Within cells, CASK was partly colocalized with ALIX, a molecule involved in exosome development, and these two molecules were coprecipitated from M2 macrophages. Moreover, exosomes derived from M2 macrophages induced podocyte cytoskeleton alterations and increased podocyte motility. Conclusion: These results suggest that the soluble permeability factor CASK is secreted by monocytes and M2 macrophages, via exosomes, to alter the glomerular filtration barrier in rFSGS.
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Affiliation(s)
- Xiaomeng Zhang
- INSERM U1197, Villejuif, France.,Division of Internal Medicine, Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Florence Herr
- INSERM U1197, Villejuif, France.,University of Paris-Saclay, Saint-Aubin, France.,Centre de Reference Maladie Rare du Syndrome Nephrotique Idiopatique, Paris, France
| | - Amelia Vernochet
- INSERM U1197, Villejuif, France.,University of Paris-Saclay, Saint-Aubin, France
| | - Hans K Lorenzo
- INSERM U1197, Villejuif, France.,University of Paris-Saclay, Saint-Aubin, France.,Department of Nephrology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Séverine Beaudreuil
- INSERM U1197, Villejuif, France.,Department of Nephrology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Antoine Dürrbach
- INSERM U1197, Villejuif, France.,University of Paris-Saclay, Saint-Aubin, France.,Centre de Reference Maladie Rare du Syndrome Nephrotique Idiopatique, Paris, France.,Department of Nephrology, Henri Mondor Hospital, Creteil, France
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34
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Figueiredo Júnior HE, Nascimento E, Lasmar MF, Siqueira RG, Sousa RN, Fabreti-Oliveira RA. Effect of Glomerulopathy Recurrence in the Outcome and Graft Survival of Kidney Transplanted Patients. Transplant Proc 2020; 52:1272-1278. [PMID: 32245622 DOI: 10.1016/j.transproceed.2020.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 02/05/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Recurrent glomerulopathy (GP) after kidney transplantation is a complication of kidney transplantation that could negatively affect kidney function and graft survival. This study aimed to evaluate the outcome, graft survival, and GP recurrence and its predictive factors in kidney-transplanted patients. METHODS Patients were divided into 2 groups: G1 (with GP; n = 95) and G2 (with other causes of end-stage renal disease; n = 373). Graft survival analyses were performed using the Kaplan-Meier for living donor (LD) and deceased donor (DD). Cox proportional hazards regression were used to investigate the predictors for graft loss and for GP recurrence. RESULTS Disease recurrence was observed in 9 patients who received a kidney from an LD, of which 4 lost their grafts. In patients who received a kidney from a DD, recurrence was also observed in 9 patients, of which 3 lost their grafts. No statistically significant differences in graft survival between G1 and G2 in relation to LD and DD were noted (P = .299 and .434, respectively). However, differences in graft survival were found when GP subtypes and GP recurrence were analyzed. The predictors of graft loss were delayed graft function (hazard ratio [HR] = 2.226, P = .002), rejection episodes (HR = 1.904, P = .017), and recurrence or transplant GP (HR = 3.243, P = .006). The predictors of disease recurrence or transplant GP were age (HR = 0.945, P = .028) and cold ischemia time (HR = 1.117, P = .003). CONCLUSION Kidney transplantation could be a reasonable treatment for GP with end-stage renal disease. Despite the disease recurrence, which is a significant cause of graft loss in transplant recipients, graft survival remains satisfactory.
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Affiliation(s)
| | - Evaldo Nascimento
- Faculty of Medical Sciences, Belo Horizonte, Brazil; IMUNOLAB - Laboratory of Histocompatibility, Belo Horizonte, Brazil
| | - Marcus F Lasmar
- Faculty of Medical Sciences, Belo Horizonte, Brazil; University Hospital of the Faculty of Medical Science, Belo Horizonte, Brazil
| | | | | | - Raquel A Fabreti-Oliveira
- Faculty of Medical Sciences, Belo Horizonte, Brazil; IMUNOLAB - Laboratory of Histocompatibility, Belo Horizonte, Brazil.
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Different effects of rituximab on a native kidney and a post-transplant kidney with recurrence of focal segmental glomerulosclerosis. CEN Case Rep 2020; 9:195-199. [PMID: 31997159 DOI: 10.1007/s13730-020-00451-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 01/18/2020] [Indexed: 11/27/2022] Open
Abstract
We present the case of a 29-year-old woman with focal segmental glomerulosclerosis (FSGS) who was treated with rituximab administration under different conditions for refractory nephrotic syndrome and posttransplant FSGS recurrence. At the age of 13 years, she developed FSGS, which followed a refractory clinical course, and eventually necessitated her to undergo plasmapheresis and receive rituximab at the age of 25 years. However, both therapies were ineffective, and she subsequently had progressive renal failure, for which dialysis was initiated at the age of 26 years. At the age of 28 years, she received a renal transplant from a living donor. However, nearly 1 year after the transplantation, nephrotic-range proteinuria was observed and FSGS recurrence was confirmed via biopsy of the transplanted kidney. Plasmapheresis resulted in complete remission, which was maintained by rituximab administration, and the patient followed a favorable course. To date, there have been no reports on the effect of rituximab on both the native kidney and post-transplant FSGS recurrence in the same patient. Interestingly, this case showed different responses to rituximab administration.
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36
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Jacobs-Cachá C, Puig-Gay N, Helm D, Rettel M, Sellarès J, Meseguer A, Savitski MM, Moreso FJ, Soler MJ, Seron D, Lopez-Hellin J. A misprocessed form of Apolipoprotein A-I is specifically associated with recurrent Focal Segmental Glomerulosclerosis. Sci Rep 2020; 10:1159. [PMID: 31980684 PMCID: PMC6981185 DOI: 10.1038/s41598-020-58197-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 01/10/2020] [Indexed: 12/29/2022] Open
Abstract
Apolipoprotein A-Ib (ApoA-Ib) is a high molecular weight form of Apolipoprotein A-I (ApoA-I) found specifically in the urine of kidney-transplanted patients with recurrent idiopathic focal segmental glomerulosclerosis (FSGS). To determine the nature of the modification present in ApoA-Ib, we sequenced the whole APOA1 gene in ApoA-Ib positive and negative patients, and we also studied the protein primary structure using mass spectrometry. No genetic variations in the APOA1 gene were found in the ApoA-Ib positive patients that could explain the increase in its molecular mass. The mass spectrometry analysis revealed three extra amino acids at the N-Terminal end of ApoA-Ib that were not present in the standard plasmatic form of ApoA-I. These amino acids corresponded to half of the propeptide sequence of the immature form of ApoA-I (proApoA-I) indicating that ApoA-Ib is a misprocessed form of proApoA-I. The description of ApoA-Ib could be relevant not only because it can allow the automated analysis of this biomarker in the clinical practice but also because it has the potential to shed light into the molecular mechanisms that cause idiopathic FSGS, which is currently unknown.
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Affiliation(s)
- Conxita Jacobs-Cachá
- Nephrology Research Group, Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. .,Nephrology Department, Hospital Vall d'Hebrón, Barcelona, Spain.
| | - Natàlia Puig-Gay
- Renal Physiopathology Group-CIBBIM. Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Dominic Helm
- Proteomics Core Facility, European Molecular Biology Laboratory, Heidelberg, Germany
| | - Mandy Rettel
- Proteomics Core Facility, European Molecular Biology Laboratory, Heidelberg, Germany
| | - Joana Sellarès
- Nephrology Research Group, Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.,Nephrology Department, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Anna Meseguer
- Renal Physiopathology Group-CIBBIM. Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Mikhail M Savitski
- Proteomics Core Facility, European Molecular Biology Laboratory, Heidelberg, Germany.,Genome Biology, European Molecular Biology Laboratory, Heidelberg, Germany
| | - Francesc J Moreso
- Nephrology Research Group, Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.,Nephrology Department, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Maria José Soler
- Nephrology Research Group, Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.,Nephrology Department, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Daniel Seron
- Nephrology Research Group, Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.,Nephrology Department, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Joan Lopez-Hellin
- Renal Physiopathology Group-CIBBIM. Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. .,Biochemistry Department, Hospital Vall d'Hebrón, Barcelona, Spain.
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Salvadori M, Tsalouchos A. Therapeutic apheresis in kidney transplantation: An updated review. World J Transplant 2019; 9:103-122. [PMID: 31750088 PMCID: PMC6851502 DOI: 10.5500/wjt.v9.i6.103] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
Therapeutic apheresis is a cornerstone of therapy for several conditions in transplantation medicine and is available in different technical variants. In the setting of kidney transplantation, immunological barriers such as ABO blood group incompatibility and preformed donor-specific antibodies can complicate the outcome of deceased- or living- donor transplantation. Postoperatively, additional problems such as antibody-mediated rejection and a recurrence of primary focal segmental glomerulosclerosis can limit therapeutic success and decrease graft survival. Therapeutic apheresis techniques find application in these issues by separating and selectively removing exchanging or modifying pathogenic material from the patient by an extracorporeal aphaeresis system. The purpose of this review is to describe the available techniques of therapeutic aphaeresis with their specific advantages and disadvantages and examine the evidence supporting the application of therapeutic aphaeresis as an adjunctive therapeutic option to immunosuppressive agents in protocols before and after kidney transplantation.
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Affiliation(s)
- Maurizio Salvadori
- Department of Transplantation Renal Unit, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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38
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Auñón P, Polanco N, Pérez-Sáez MJ, Rodrigo E, Sancho A, Pascual J, Andrés A, Praga M. Pre-emptive rituximab in focal and segmental glomerulosclerosis patients at risk of recurrence after kidney transplantation. Clin Kidney J 2019; 14:139-148. [PMID: 33564412 PMCID: PMC7857812 DOI: 10.1093/ckj/sfz120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 08/08/2019] [Indexed: 12/12/2022] Open
Abstract
Background The recurrence of proteinuria after kidney transplantation (KT) is a characteristic complication of focal segmental glomerulosclerosis (FSGS). It has been suggested that pre-emptive rituximab might prevent recurrences in patients at risk, but there is no agreement about which factors might help to identify such patients. Methods We studied 93 kidney transplants with biopsy-proven idiopathic FSGS in order to analyse if preventive rituximab treatment could decrease recurrences in patients at risk. Results Fifteen patients (16.1%) presented a recurrence after KT, but when we restricted the analysis to the 34 patients presenting nephrotic syndrome at primary disease onset, the recurrence diagnosis rate increased to 44.1%. All patients with recurrence had complete nephrotic syndrome at the time of diagnosis. After multivariate adjustment, the only significant risk factor for recurrence was the presence of complete nephrotic syndrome at diagnosis. Twelve of the 34 patients at risk for recurrence received rituximab at the time of transplantation. Clinical and analytical characteristics were similar in all patients at risk. The number of recurrences was similar among treated (50%) and non-treated patients (40.9%). Conclusions Nephrotic syndrome with hypoalbuminaemia at diagnosis is the most important feature to identify patients at risk of recurrence. Our data suggest that pre-emptive rituximab is not effective to prevent FSGS recurrences.
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Affiliation(s)
- Pilar Auñón
- Nephrology Department, Hospital Doce de Octubre, Madrid, Spain
| | - Natalia Polanco
- Nephrology Department, Hospital Doce de Octubre, Madrid, Spain
| | | | - Emilio Rodrigo
- Nephrology Department, Hospital Marqués de Valdecilla, Santander, Spain
| | - Asunción Sancho
- Nephrology Department, Hospital Doctor Peset, Valencia, Spain
| | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Amado Andrés
- Nephrology Department, Hospital Doce de Octubre, Madrid, Spain
| | - Manuel Praga
- Nephrology Department, Hospital Doce de Octubre, Madrid, Spain.,Department of Medicine, Complutense University, Madrid, Spain
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Koh LJ, Martz K, Blydt-Hansen TD. Risk factors associated with allograft failure in pediatric kidney transplant recipients with focal segmental glomerulosclerosis. Pediatr Transplant 2019; 23:e13469. [PMID: 31169337 DOI: 10.1111/petr.13469] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/08/2019] [Accepted: 02/11/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND With improved outcomes for children transplanted with FSGS since previous NAPRTCS registry reports, this study re-evaluates the association of living donation, immunosuppression, and DGF on graft survival. SETTING Patients transplanted between 2002 and 2016, comparing FSGS diagnosis vs other glomerular diseases. METHODS Primary outcomes were allograft survival and FSGS recurrent-free graft survival. Potential risk factors were obtained at the time of transplant and up to 30 days post-transplantation. Analysis considered a priori that DGF may be a proxy for severe FSGS recurrence. Multivariable survival models for outcome were tested for sensitivity without/with DGF to determine features independent of recurrence. RESULTS From the larger cohort of 3010 patients, 5-year graft survival in children with FSGS (n = 455) was worse (74.3%) compared with other glomerular diseases (87.1%, n = 690) (HR 1.45, P = 0.033). Modeling all glomerular diseases, survival risk was associated with deceased donor (HR 1.83, P = 0.002), re-transplantation (HR 1.58, P = 0.013), and recipient age (HR 1.06/y, P = 0.002). The living donor advantage was not confirmed in a FSGS model (HR 1.51 for deceased, P = 0.12). DGF was highly associated with graft failure (HR 4.39, P < 0.001) and independent of re-transplant history but not FSGS diagnosis. Induction agents or primary immunosuppression choices were not associated with survival. CONCLUSION Graft survival rates have improved since the previous report. Living donor did not predict graft failure, but there remains no survival advantage. DGF was the primary independent predictor for graft loss secondary to FSGS recurrence, consistent with DGF being a proxy for severe recurrent disease.
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Affiliation(s)
- Lee Jin Koh
- Paediatric Nephrology, National University Hospital System, Singapore, Singapore.,Pediatric Nephrology, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Karen Martz
- EMMES Corporation, Rockville, Maryland, United States of America
| | - Tom David Blydt-Hansen
- Multi Organ Transplant Program, BC Children's Hospital, Vancouver, British Columbia, Canada
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40
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Kienzl-Wagner K, Waldegger S, Schneeberger S. Disease Recurrence-The Sword of Damocles in Kidney Transplantation for Primary Focal Segmental Glomerulosclerosis. Front Immunol 2019; 10:1669. [PMID: 31379860 PMCID: PMC6652209 DOI: 10.3389/fimmu.2019.01669] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/04/2019] [Indexed: 12/21/2022] Open
Abstract
A major obstacle in kidney transplantation for primary focal segmental glomerulosclerosis (FSGS) is the risk of disease recurrence. Recurrent FSGS affects up to 60% of first kidney grafts and exceeds 80% in patients who have lost their first graft due to recurrent FSGS. Clinical and experimental evidence support the hypothesis that a circulating permeability factor is the mediator in the pathogenesis of primary and recurrent disease. Despite all efforts, the causing agent has not yet been identified. Several treatment options for the management of recurrent FSGS have been proposed. In addition to plasma exchange, B-cell depleting antibodies are effective in recurrent FSGS. This indicates, that the secretion and/or activity of the postulated circulating permeability factor(s) may be B-cell related. This review summarizes the current knowledge on permeability factor(s) possibly related to the disease and discusses strategies for the management of recurrent FSGS. These include profound B-cell depletion prior to transplantation, as well as the salvage of an allograft affected by recurrent FSGS by transfer into a second recipient.
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Affiliation(s)
- Katrin Kienzl-Wagner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Siegfried Waldegger
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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41
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Shah Y, Almeshari K, Aleid H, Broering D, Alahmadi I, Ali T. Successful Treatment With Abatacept in Recurrent Focal Segmental Glomerulosclerosis After Kidney Transplant. EXP CLIN TRANSPLANT 2019; 17:178-180. [PMID: 30777550 DOI: 10.6002/ect.mesot2018.p53] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Primary focal segmental glomerulosclerosis recurrence occurs in 10% to 50% of recipients after kidney transplant and may affect both children and adults. Treatment after recurrence with plasma exchange and immunosuppression is quite variable and challenging, and those who do not respond usually progress to allograft failure. Podocyte injury and B7-1 expression and subsequently its blockade (abatacept) have been reported to be associated with complete remission of proteinuria in 4 patients with focal segmental glomerulosclerosis recurrence after kidney transplantation and in 1 patient with focal segmental glomerulosclerosis in native kidney. Here, we report our experience of successfully treating 3 consecutive patients with focal segmental glomerulosclerosis recurrence after kidney transplant with abatacept, which induced proteinuria remission.
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Affiliation(s)
- Yaser Shah
- From the Department of Adult Kidney and Pancreas Transplantation, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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42
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Bouts A, Veltkamp F, Tönshoff B, Vivarelli M. European Society of Pediatric Nephrology survey on current practice regarding recurrent focal segmental glomerulosclerosis after pediatric kidney transplantation. Pediatr Transplant 2019; 23:e13385. [PMID: 30825259 DOI: 10.1111/petr.13385] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Primary FSGS is an important cause of ESRD in children. FSGS recurrence after kidney transplantation is associated with early graft loss. No guidelines for treatment of FSGS recurrence exist. We conducted a survey to gain insight into variation of treatment between centers. METHODS A survey was sent to all members of the ESPN on behalf of the "Renal Transplantation" and "Idiopathic Nephrotic Syndrome" working groups. RESULTS Fifty-nine nephrologists from 31 countries responded, reporting 807 FSGS patients, with 241 (30%) FSGS recurrences after transplantation. Recurrence varied from 0% to 100% between respondents. Native nephrectomy before or during transplantation was performed, respectively, always (37%), never (39%), or on clinical indication (17%). Half of the respondents started preventive treatment before transplantation, using PF (n = 10); R (n = 4); PF or IA, plus R (n = 9); cyclosporine (n = 2); or unknown (n = 4). Immunosuppressive therapy for patients without known mutations consisted of a combination of steroids, tacrolimus/cyclosporine, and MMF, with or without IL-2R-blockade in, respectively, 61% and 86% of the respondents. Sixty-three percent applied a similar regimen to patients with known mutations. FSGS recurrence was treated with PF or IA, plus R by 66% of respondents; 54% observed no response. Complete remission in >50% of patients was reported by 41% of the respondents. DISCUSSION FSGS recurrence after transplantation is common, but varies greatly between centers. We found great variability in preventive and therapeutic treatment regimens. Future research should focus on predisposing factors, including biopsy findings and genetic mutations, and standardized treatment.
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Affiliation(s)
- Antonia Bouts
- Department of Pediatric Nephrology, Emma Children's Hospital, AMC, Amsterdam, the Netherlands
| | - Floor Veltkamp
- Department of Pediatric Nephrology, Emma Children's Hospital, AMC, Amsterdam, the Netherlands
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Marina Vivarelli
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
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43
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El Khashab S, El Khashab O, El Ghoneimy M, AbdelRassoul MA. Rituximab as a Preemptive Treatment to Prevent Recurrence of Primary Focal Segmental Glomerulosclerosis: A Novel Approach. EXP CLIN TRANSPLANT 2019; 17:326-329. [PMID: 30880653 DOI: 10.6002/ect.2018.0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Primary idiopathic focal segmental glomerulo-sclerosis is a serious disease, frequently progressing to end-stage kidney failure. Management of recurrence after kidney transplant is challenging despite multiple proposed therapeutic approaches. Available treatment for focal segmental glomeru-losclerosis recurrence is plasma exchange, intravenous cyclosporine, and rituximab. In this study, we investigated kidney transplant recipients with focal segmental glomerulosclerosis who were at high risk for recurrence. Patients were given preemptive rituximab at day 0 posttransplant. MATERIALS AND METHODS Between January 2013 and June 2017, our center had 8 patients with primary focal segmental glomerulosclerosis at high risk for recurrence who were scheduled for kidney transplant. These patients received a single rituximab infusion of 375 mg/m2 on day 0 posttransplant. Recurrence of focal segmental glomerulosclerosis posttransplant was defined as repeated proteinuria > 2 g/day, without evidence of clinical or biopsy-proven rejection. RESULTS Follow-up showed that none of our patients had immediate posttransplant proteinuria. Only 1 patient developed proteinuria at almost 4 months posttransplant. Mean follow-up duration was 8 months. With regard to complications, 2 patients had serious bacterial infections and 1 patient had cytomegalovirus infection. CONCLUSIONS Rituximab at day 0 posttransplant may be used safely to prevent focal segmental glomeru-losclerosis recurrence in the graft in the early posttransplant period. However, longer follow-up studies with larger series are needed.
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Affiliation(s)
- Sahier El Khashab
- From the Department of Internal Medicine and Nephrology, Cairo University, Cairo, Egypt
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44
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Chronological change of renal pathological findings in the proliferative glomerulonephritis with monoclonal IgG deposits considered to have recurred early after kidney transplantation. CEN Case Rep 2019; 8:151-158. [PMID: 30805792 DOI: 10.1007/s13730-019-00384-6] [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] [Received: 08/24/2018] [Accepted: 01/23/2019] [Indexed: 10/27/2022] Open
Abstract
Proliferative glomerulonephritis with monoclonal immunoglobulin G (IgG) deposits (PGNMID) is a rare disease that recently became recognized. Its pathological findings are characterized by the deposition of a single heavy chain subclass and a single light chain isotype. PGNMID has been proven to recur in renal allografts. Herein, the authors describe the case of a 46-year-old man who presented with nephrotic syndrome and progressive kidney injury following kidney transplantation. One month after transplantation, his clinical condition stabilized; however, the protocol biopsy showed depositions of IgG and complement on the glomeruli by immunofluorescence staining. Electron microscopy (EM) revealed granular electron-dense deposits (EDD) in the mesangium. Thereafter, renal biopsy was repeated because his proteinuria level increased. Proliferative glomerulonephritis, mainly in the mesangium, with IgG and complement deposits and mesangial and subendothelial EDD were observed; however, the pathological diagnosis was difficult. Renal dysfunction then became apparent, and renal biopsy was performed again 4 years and 10 months after kidney transplantation. Glomerular deposits on a single IgG subclass and a single light chain isotype (IgG3 kappa) with membranoproliferative features were observed. Abundant subendothelial EDD were detected on EM. Finally, the patient was diagnosed with PGNMID. Since it seemed that PGNMID had already developed at 1 month after transplantation, we considered recurrent PGNMID case in the allograft. The treatment for PGNMID has not been established yet, and even in this case, the graft function was eventually lost. For improving renal prognosis, early diagnosis and further investigation on the treatment are necessary.
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45
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Successful management of post-transplant focal segmental glomerulosclerosis with therapeutic plasma exchange and rituximab. Clin Exp Nephrol 2019; 23:700-709. [DOI: 10.1007/s10157-019-01690-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/02/2019] [Indexed: 02/06/2023]
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46
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Tullus K, Webb H, Bagga A. Management of steroid-resistant nephrotic syndrome in children and adolescents. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:880-890. [PMID: 30342869 DOI: 10.1016/s2352-4642(18)30283-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/18/2018] [Accepted: 08/21/2018] [Indexed: 02/08/2023]
Abstract
More than 85% of children and adolescents (majority between 1-12 years old) with idiopathic nephrotic syndrome show complete remission of proteinuria following daily treatment with corticosteroids. Patients who do not show remission after 4 weeks' treatment with daily prednisolone are considered to have steroid-resistant nephrotic syndrome (SRNS). Renal histology in most patients shows presence of focal segmental glomerulosclerosis, minimal change disease, and (rarely) mesangioproliferative glomerulonephritis. A third of patients with SRNS show mutations in one of the key podocyte genes. The remaining cases of SRNS are probably caused by an undefined circulating factor. Treatment with calcineurin inhibitors (ciclosporin and tacrolimus) is the standard of care for patients with non-genetic SRNS, and approximately 70% of patients achieve a complete or partial remission and show satisfactory long-term outcome. Additional treatment with drugs that inhibit the renin-angiotensin axis is recommended for hypertension and for reducing remaining proteinuria. Patients with SRNS who do not respond to treatment with calcineurin inhibitors or other immunosuppressive drugs can show declining kidney function and are at risk for end-stage renal failure. Approximately a third of those who undergo renal transplantation show recurrent focal segmental glomerulosclerosis in the allograft and often respond to combined treatment with plasma exchange, rituximab, and intensified immunosuppression.
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Affiliation(s)
- Kjell Tullus
- Nephrology Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK.
| | - Hazel Webb
- Nephrology Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
| | - Arvind Bagga
- Division of Nephrology, Indian Council of Medical Research Advanced Center for Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
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47
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Abstract
Rituximab is a chimeric anti-CD20 monoclonal protein used in various clinical scenarios in kidney transplant recipients. However, its evidence-based use there remains limited due to lack of controlled studies, limited sample size, short follow-up and poorly defined endpoints. Rituximab is indicated for CD20+ posttransplant lymphoproliferative disorder. It may be beneficial for treating recurrent membranous nephropathy and recurrent allograft antineutrophilic cytoplasmic antibody vasculitis and possibly for recurrent focal segmental glomerulosclerosis. Rituximab, in combination with IVIg/plasmapheresis, appears to decrease antibody level and increase the odds of transplantation in sensitized recipients. The role of Rituximab in ABOi transplant remains unclear, as similar outcomes are achieved without its use. Rituximab is not efficacious in antibody-mediated rejection/chronic antibody-mediated rejection. Strict randomized control trials are necessary to elucidate its true role in these settings.
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48
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Wong AY, John RM. Diagnosis and primary care management of focal segmental glomerulosclerosis in children. Nurse Pract 2018; 43:28-37. [PMID: 30134435 DOI: 10.1097/01.npr.0000544275.97385.73] [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: 06/08/2023]
Abstract
Focal segmental glomerulosclerosis (FSGS) is a pattern of kidney damage that can occur in individuals at any age, including children. Pediatric patients with FSGS require medication monitoring, growth, and psychological health. This article discusses the NP's role in the clinical presentation, diagnostic workup, and treatment of FSGS in pediatric patients.
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Affiliation(s)
- Angela Y Wong
- Angela Y. Wong is a pediatric NP at Maimonides Children's Hospital, Brooklyn, N.Y. Rita Marie John is a PNP program director and associate professor of nursing at Columbia University Medical Center, Columbia University School of Nursing, New York, N.Y
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49
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Momtaz M, Fayed A, Marzouk K, Shaker A. Therapeutic Plasma Exchange Outcomes in Cairo University Hospitals: 6 Years Experience. Ther Apher Dial 2018; 22:666-673. [DOI: 10.1111/1744-9987.12710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/08/2018] [Accepted: 05/08/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Mohamed Momtaz
- Department of Internal Medicine, Nephrology Unit; Cairo University Hospital; Cairo Egypt
| | - Ahmed Fayed
- Department of Internal Medicine, Nephrology Unit; Cairo University Hospital; Cairo Egypt
| | - Khaled Marzouk
- Department of Internal Medicine, Nephrology Unit; Cairo University Hospital; Cairo Egypt
| | - Amr Shaker
- Department of Internal Medicine, Nephrology Unit; Cairo University Hospital; Cairo Egypt
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50
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Sakai K, Oguchi H, Muramatsu M, Shishido S. Protocol graft biopsy in kidney transplantation. Nephrology (Carlton) 2018; 23 Suppl 2:38-44. [DOI: 10.1111/nep.13282] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Ken Sakai
- Department of Nephrology, Faculty of Medicine; Toho University; Tokyo Japan
| | - Hideyo Oguchi
- Department of Nephrology, Faculty of Medicine; Toho University; Tokyo Japan
| | - Masaki Muramatsu
- Department of Nephrology, Faculty of Medicine; Toho University; Tokyo Japan
| | - Seiichiro Shishido
- Department of Nephrology, Faculty of Medicine; Toho University; Tokyo Japan
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