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Mansur J, Chang-Dávila D, Simões MG, Cristelli MP, Stopa Martins SB, de Sousa Proença HM, Viana LA, Ferreira AN, Doher MP, Medina-Pestana J, Mastroianni Kirsztajn G, Tedesco-Silva H. Multiple-target Therapy for Posttransplant Focal Segmental Glomerulosclerosis. Transplant Direct 2024; 10:e1651. [PMID: 38817628 PMCID: PMC11139459 DOI: 10.1097/txd.0000000000001651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 06/01/2024] Open
Abstract
Background There is no consensus on the ideal strategy to treat posttransplant focal segmental glomerulosclerosis. The multiple-target therapy, which consisted of high-dose intravenous cyclosporine, prednisone, and plasmapheresis, showed favorable results. Methods This single-center, prospective study sought to evaluate the multiple-target therapy in an independent cohort of patients. Results Thirteen patients with posttransplant focal segmental glomerulosclerosis received multiple-target therapy. Complete remission was achieved in 2 patients (15.4%), and partial remission in another 2 patients (15.4%). Four patients (30.7%) did not show remission, and 5 patients (38%) lost the graft because of posttransplant focal segmental glomerulosclerosis during the 12-mo follow-up. Premature discontinuation of treatment occurred in 10 patients (77%), all associated with infectious adverse events. Cytomegalovirus was the most common complication, and preemptive therapy was used instead of prophylaxis. Conclusions In this cohort of patients, the efficacy of the multiple-target therapy was poor and limited by the high incidence of infectious adverse events.
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Affiliation(s)
- Juliana Mansur
- Nephrology Division, Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Marcela Giraldes Simões
- Nephrology Division, Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | | | | | - Laila Almeida Viana
- Nephrology Division, Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
| | | | | | - José Medina-Pestana
- Nephrology Division, Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Helio Tedesco-Silva
- Nephrology Division, Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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2
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Zhu Y, Fan Y, Xu F, Liang S, Liang D, Li P, Xia Y, Zhu X, Yang F, Chen J, Zeng C. Focal Segmental Glomerulosclerosis Superimposed on Transplant Glomerulopathy: Implications for Graft Survival. Am J Nephrol 2021; 52:788-797. [PMID: 34749369 DOI: 10.1159/000519648] [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: 07/26/2021] [Accepted: 09/13/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Transplant glomerulopathy (TG) is a morphological lesion resulting from chronic glomerular endothelium injury, and it is strongly associated with poor graft survival. TG coexisting with focal segmental glomerulosclerosis (FSGS) can be found in renal allograft biopsies, but few related studies are available. METHODS Consecutive kidney transplant recipients with biopsy-proven TG were studied retrospectively. Patients concomitant with FSGS were identified and compared with those without FSGS. The influence of FSGS on allograft outcomes was assessed using univariate and multivariate Cox regression models. RESULTS Of the 66 patients with TG, 40 (60.6%) had concomitant FSGS. TG patients with FSGS had higher proteinuria (median, 2.6 vs. 0.8 g/24 h, p < 0.001) and serum creatinine levels (median, 2.5 vs. 2.1 mg/dL, p = 0.04), lower serum albumin levels, higher chronic glomerulopathy (cg) score, larger glomerular tuft area, lower number of podocytes, and higher incidences of podocyte hyperplasia, pseudotubule formation, and diffuse foot process effacement than those without FSGS (all p < 0.05). The kidney allograft loss rate of patients with FSGS was higher than that of patients without FSGS (65.7% vs. 37.5%, p = 0.03). The presence of FSGS was independently associated with allograft loss in TG (hazard ratio (HR) = 3.42, 95% confidence interval (CI): 1.30-8.98, p = 0.01). Other independent predictors were proteinuria (HR = 1.18, 95% CI: 1.02-1.37, p = 0.02), estimated glomerular filtration rate (HR = 0.94, 95% CI: 0.91-0.97, p < 0.001), and panel reactive antibody (HR = 3.99, 95% CI: 1.14-13.99, p = 0.03). Moreover, FSGS (odds ratio (OR) = 4.39, 95% CI: 1.29-14.92, p = 0.02) and cg (OR = 5.36, 95% CI: 1.56-18.40, p = 0.01) were independent risk factors for proteinuria. CONCLUSION In this cohort of patients with TG, the presence of FSGS was strongly associated with more severe clinicopathological features and worse allograft survival.
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Affiliation(s)
- Ying Zhu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Yun Fan
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Feng Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Shaoshan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Dandan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Ping Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Yuanyuan Xia
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiaodong Zhu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Fan Yang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Jinsong Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing Medical University, Nanjing, China
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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3
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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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4
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Rosa-Guerrero P, Leiva-Cepas F, Agüera-Morales M, Navarro-Cabello MD, Rodríguez-Benot A, Torres-De-Rueda A. First Report in the Literature of Biopsy-Proven Noncollapsing Focal Segmental Glomerulosclerosis Relapse in a Second Renal Transplant Presenting With Thrombotic Microangiopathy: A Case Report. Transplant Proc 2021; 53:2747-2750. [PMID: 34627595 DOI: 10.1016/j.transproceed.2021.07.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/16/2021] [Indexed: 11/30/2022]
Abstract
Primary focal segmental glomerulosclerosis (FSGS) is a podocytopathy with an irregular response to immunosuppressive therapies. FSGS relapse occurs in 30% to 80% of kidney grafts, and poor survival outcomes include large proteinuria and the nephrotic syndrome's cardinal clinical features. Thrombotic microangiopathy (TMA) is caused by endothelial injury due to complement dysregulation including acute kidney injury, proteinuria, and severe hypertension common renal presentations. Both pathologies have well-described genetic forms, but their relationship remains uncertain. FSGS lesions can be found in kidney biopsy specimens in patients with TMA, and TMA has been reported in patients with collapsing glomerulopathy. However, this combination has not been clearly described in renal transplant recipients. We present the case of a 22-year-old man who received his second kidney allograft and developed an early graft disfunction with nephrotic syndrome and clinical TMA. His background was remarkable for primary, biopsy-confirmed FSGS in childhood, and he started hemodialysis in 2006 and received a living donor kidney graft the same year. He presented with a FSGS relapse with malignant hypertension and seizures in the first posttransplant month and had an irregular response to plasma exchange and rituximab, and dialysis was reinitiated 10 years later. A total of 3 biopsies were performed after his second kidney transplant showing the evolution of a FSGS relapse with histologic and clinical TMA in the absence of identified genetic mutations. Partial responses to treatments with plasma exchange, eculizumab, and rituximab were obtained, but the allograft was lost after 26 months. This case is the first report of concomitant FSGS and TMA in a renal transplant recipient.
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Affiliation(s)
- Pedro Rosa-Guerrero
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain.
| | - Fernando Leiva-Cepas
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Pathology, Reina Sofía University Hospital, Córdoba, Spain
| | - Marisa Agüera-Morales
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain
| | - María Dolores Navarro-Cabello
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain
| | - Alberto Rodríguez-Benot
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain
| | - Alvaro Torres-De-Rueda
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain; Asociación Medicina e Investigación (AMI), Córdoba, Spain
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5
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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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