The urgent need for more research on how to treat recurrent focal and segmental glomerulosclerosis

Treatment of post-transplant recurrent FSGS in children using plasmapheresis and augmentation of immunosuppression

Background

Up to 60% of pediatric renal transplant recipients with end-stage renal disease due to primary focal and segmental glomerulosclerosis (FSGS) may develop recurrent disease. Such recurrence is associated with poor prognosis if no remission is achieved. We report a single center experience with a protocol based on plasmapheresis and increased immunosuppression that resulted in a high long-lived remission rate.

Methods

This retrospective cohort study included consecutive pediatric renal transplant patients with recurrent FSGS treated with a standardized protocol using plasmapheresis and cyclophosphamide to supplement usual post-transplant immunosuppression with calcineurin inhibitors and steroids. Relapse was defined as urinary protein/creatinine ratio > 1.0 g/g and remission as < 0.5 g/g.

Results

Seventeen patients with FSGS recurrence post-transplant were treated. All had therapy resistant FSGS in native kidneys and had been on dialysis from 4 to 10 years. Of the 17, one died perioperatively from a pulmonary thromboembolism. Fifteen others achieved a complete remission within 3 months of treatment for FSGS recurrence. After a median follow-up period of 4 years, there were no recurrences of significant proteinuria. One patient achieved remission with rituximab.

Conclusion

The addition of plasmapheresis and cyclophosphamide to a calcineurin- and steroid-based immunosuppression regime was highly successful in inducing high remission rates with recurrent FSGS. Prospective trials are needed to evaluate further the efficacy of increased immunosuppression along with plasmapheresis in this setting.

High depression rates among pediatric renal replacement therapy patients: A cross-sectional study

Depression is common in pediatric chronic kidney disease (CKD) patients. Depression is associated with inferior long-term outcomes. There is a paucity of studies that evaluate depression and possible associated factors in children and adolescents requiring renal replacement therapy (RRT). Cross-sectional study using Children`s Depression Inventory in a cohort from a large urban center. Forty-seven pediatric RRT patients (26 female, 12 peritoneal dialysis (PD), 17 hemodialysis (HD), 18 after successful kidney transplantation (KTX)) with a mean age at the time of assessment of 13.9 ± 2.3 years. Symptoms of depression were found in 30 (64%, 11KTX, 11HD, 8PD) patients. We found no association with age, sex, renal function, dialysis adequacy markers, anemia, electrolytes, socioeconomical status, IQ, educational status of the child including school attendance and distance from the house to the hospital among HD patients. Significant differences only applied for age at diagnosis of CKD, RRT vintage and deceased donor for KTX. The group with depression had a higher age at diagnosis of CKD and less time on RRT than the group without depression. There was also a high rate of depression in KTX patients. In this cohort, depression was a common comorbidity of RRT in children and adolescents with RRT and also for KTX patients, even though biomarkers of kidney function and time for RRT are much improved.