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Rheault MN, Amaral S, Bock M, Chambers ET, Chavers B, Ters ME, Garro R, Gbadegesin R, Govil A, Harshman L, Amer H, Hooper DK, Israni AK, Riad S, Sageshima J, Shapiro R, Seifert M, Smith J, Sung R, Thomas CP, Wang Q, Verghese PS. A randomized controlled trial of preemptive rituximab to prevent recurrent focal segmental glomerulosclerosis post-kidney transplant (PRI-VENT FSGS): protocol and study design. FRONTIERS IN NEPHROLOGY 2023; 3:1181076. [PMID: 37675355 PMCID: PMC10479749 DOI: 10.3389/fneph.2023.1181076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/17/2023] [Indexed: 09/08/2023]
Abstract
Background Focal segmental glomerulosclerosis (FSGS) is a common cause of end-stage kidney disease requiring kidney transplantation and can recur in the allograft in 30-80% of recipients resulting in reduced graft survival. Plasmapheresis has shown efficacy in treating some cases of recurrent FSGS but isolated plasmapheresis has not demonstrated efficacy in preventing recurrent FSGS. Rituximab has had anecdotal success in preventing recurrence in a single center study but has not been studied in combination with plasmapheresis for preventing FSGS recurrence. Methods We are conducting a randomized, controlled, multicenter clinical trial of adult and pediatric kidney transplant recipients with primary FSGS to assess whether plasmapheresis in combination with rituximab prevents recurrent disease post-transplantation. Discussion Rituximab combined with plasmapheresis is a promising, novel therapy to prevent recurrent FSGS, a disease with limited therapeutic options and no consensus guidelines for prevention or treatment. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT03763643, identifier NCT03763643.
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Affiliation(s)
- Michelle N. Rheault
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Sandra Amaral
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Margret Bock
- Department of Pediatrics, Children’s Hospital of Colorado, Denver, CO, United States
| | | | - Blanche Chavers
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Mireile El Ters
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Rouba Garro
- Department of Pediatrics, Emory University, Atlanta, GA, United States
| | | | - Amit Govil
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Lyndsay Harshman
- Department of Pediatrics, University of Iowa, Iowa, IA, United States
| | - Hatem Amer
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - David K. Hooper
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Ajay K. Israni
- The Kidney Center at Hennepin Healthcare, Hennepin Health, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Samy Riad
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Junichiro Sageshima
- Department of Surgery, University of California, Davis, Davis, CA, United States
| | - Ron Shapiro
- Department of Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, United States
| | - Michael Seifert
- Heersink School of Medicine, Department of Pediatrics, School of Medicine, University of Alabama, Birmingham, AL, United States
| | - Jodi Smith
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA, United States
| | - Randall Sung
- Department of Surgery, University of Michigan Health, Ann, Arbor, MI, United States
| | - Christie P. Thomas
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Qi Wang
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, United States
| | - Priya S. Verghese
- Department of Pediatrics, Northwestern University, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL, United States
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Dudreuilh C, Barbet C, Gatault P, Ferlicot S, Lebranchu Y, Rabot N, Beaudreuil S, Dürrbach A, Büchler M. Response to plasma exchange and graft survival in recurrent focal and segmental glomerulosclerosis after transplantation: does the time of recurrence matter? A retrospective study. Transpl Int 2020; 34:302-312. [PMID: 33275815 DOI: 10.1111/tri.13796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/10/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
Recurrence of primary focal and segmental glomerulosclerosis following kidney transplantation (rFSGS) is a frequent and severe disease. We studied the time to recurrence of FSGS and its impact on the response to plasma exchange (PE) and graft survival. Between 1990 and 2013, 2730 kidney transplants were performed, including 52 patients with a primary diagnosis of FSGS. Of these patients with primary FSGS, 34 (67%) developed rFSGS. We retrospectively divided these patients into two groups depending on the time to recurrence: early (up to three months after transplantation, n = 26) or late (more than three months after transplantation, n = 8). Survival did not significantly differ between the two groups. In cases of late recurrence, PE was started later and was performed less frequently, and remission was achieved after more PE sessions and longer PE treatment than for the early group (P = 0.01). In early recurrence, resistance to PE at 40 days was associated with no long-term response to PE. PE should be performed as soon as possible after rFSGS. Patients with late rFSGS need to be offered the same treatment regime as those with early rFSGS.
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Affiliation(s)
- Caroline Dudreuilh
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
| | - Christelle Barbet
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
| | - Philippe Gatault
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
| | - Sophie Ferlicot
- Department of Pathology, Bicetre University Hospital, Le Kremlin Bicêtre, France
| | - Yvon Lebranchu
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
| | - Nolwenn Rabot
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
| | - Severine Beaudreuil
- Nephrology Department, Hopitaux Universitaires Paris-Sud, APHP, Le Kremlin-Bicetre, France.,UMR 1197, University Paris Sud, INSERM, Paris-Saclay University, Villejuif, France
| | - Antoine Dürrbach
- Nephrology Department, Hopitaux Universitaires Paris-Sud, APHP, Le Kremlin-Bicetre, France.,UMR 1197, University Paris Sud, INSERM, Paris-Saclay University, Villejuif, France
| | - Matthias Büchler
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
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3
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Solomon S, Zolotnitskaya A, Del Rio M. Ofatumumab in post-transplantation recurrence of focal segmental glomerulosclerosis in a child. Pediatr Transplant 2019; 23:e13413. [PMID: 30973669 DOI: 10.1111/petr.13413] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/21/2019] [Accepted: 02/28/2019] [Indexed: 12/15/2022]
Abstract
FSGS is a potentially devastating form of nephrotic syndrome. Treatment of SRNS can be difficult, especially post-transplantation. The current therapy of post-transplant SRNS includes plasmapheresis, ACE-I, CNI, and monoclonal antibodies (rituximab). Patients who are refractory to these interventions have limited therapeutic alternatives. We present a case of a patient with SRNS secondary to FSGS. He did not respond to immunosuppressive medications prior to transplant, progressed to ESRD, and was started on chronic hemodialysis. He received a DDKT which was complicated by post-transplant FSGS recurrence. A course of plasmapheresis, rituximab, and CNI were administered with some response. Ofatumumab was then given to the patient. As a result, the patient achieved partial remission. Ofatumumab may be a safe and effective option for post-transplant recurrence of FSGS.
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4
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Ashoor IF, Dharnidharka VR. Non-immunologic allograft loss in pediatric kidney transplant recipients. Pediatr Nephrol 2019; 34:211-222. [PMID: 29480356 DOI: 10.1007/s00467-018-3908-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/26/2018] [Accepted: 01/26/2018] [Indexed: 01/13/2023]
Abstract
Non-immunologic risk factors are a major obstacle to realizing long-term improvements in kidney allograft survival. A standardized approach to assess donor quality has recently been introduced with the new kidney allocation system in the USA. Delayed graft function and surgical complications are important risk factors for both short- and long-term graft loss. Disease recurrence in the allograft remains a major cause of graft loss in those who fail to respond to therapy. Complications of over immunosuppression including opportunistic infections and malignancy continue to limit graft survival. Alternative immunosuppression strategies are under investigation to limit calcineurin inhibitor toxicity. Finally, recent studies have confirmed long-standing observations of the significant negative impact of a high-risk age window in late adolescence and young adulthood on long-term allograft survival.
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Affiliation(s)
- Isa F Ashoor
- Division of Nephrology, LSU Health New Orleans and Children's Hospital, 200 Henry Clay Avenue, New Orleans, LA, 70130, USA.
| | - Vikas R Dharnidharka
- Washington University and St. Louis Children's Hospital, 600 South Euclid Ave, St. Louis, MO, 63110, USA
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Verghese PS, Rheault MN, Jackson S, Matas AJ, Chinnakotla S, Chavers B. The effect of peri-transplant plasmapheresis in the prevention of recurrent FSGS. Pediatr Transplant 2018; 22:e13154. [PMID: 29388290 DOI: 10.1111/petr.13154] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2017] [Indexed: 12/20/2022]
Abstract
Many pediatric centers utilize a variety of protocols including preemptive plasmapheresis to prevent the recurrence of FSGS post-transplant. But the effectiveness of this expensive, time-consuming process of plasmapheresis in the prevention of FSGS recurrence is still unclear. We retrospectively reviewed all pediatric cases of FSGS in our center that received a kidney transplant and compared the transplant and patient outcomes of those transplanted after 2006 who received pretransplant plasmapheresis to those prior to 2006 who did not. Of the 57 children with FSGS, 31 and 26 were transplanted before and after 2006, respectively. The cohorts differed significantly in keeping with the center immunosuppression protocol changes, and prior to 2006, the recipients were significantly younger. All children with FSGS transplanted after 2006 underwent three and one sessions of 1.0 plasma volume/exchange plasmapheresis with fresh frozen plasma replacement prior to the transplant in living and deceased donors, respectively, in addition to five sessions of every other day post-transplant pheresis. The incidence (27% vs 26%, P = 1.0) and time to recurrence of FSGS in the kidney allograft (P = .22) were not significantly different in patients that did and did not undergo prophylactic plasmapheresis. We need to re-evaluate the role of preemptive plasmapheresis in the prevention of FSGS recurrence in a prospective multicenter study.
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Affiliation(s)
- P S Verghese
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - M N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - S Jackson
- Informatics Services for Research and Reporting, M Health, Minneapolis, MN, USA
| | - A J Matas
- Department of Surgery, Division of Transplant Surgery, University of Minnesota, Minneapolis, MN, USA
| | - S Chinnakotla
- Department of Surgery, Division of Transplant Surgery, University of Minnesota, Minneapolis, MN, USA
| | - B Chavers
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
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Grenda R, Jarmużek W, Rubik J, Piątosa B, Prokurat S. Rituximab is not a "magic drug" in post-transplant recurrence of nephrotic syndrome. Eur J Pediatr 2016; 175:1133-1137. [PMID: 27364906 PMCID: PMC5005389 DOI: 10.1007/s00431-016-2747-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/12/2016] [Accepted: 06/15/2016] [Indexed: 01/26/2023]
Abstract
UNLABELLED Pediatric patients with end-stage renal failure due to severe drug-resistant nephrotic syndrome are at risk of rapid recurrence after renal transplantation. Treatment options include plasmapheresis, high-dose of cyclosporine A/methylprednisolone and more recently-rituximab (anti-B CD20 monoclonal depleting antibody). We report five patients with immediate (1-2 days) post-transplant recurrence of nephrotic syndrome, treated with this kind of combined therapy including 2-4 weekly doses of 375 mg/m(2) of rituximab. Only two (of five) patients have showed full long-term remission, while the partial remission was seen in two cases, and no clinical effect at all was achieved in one patient. The correlation between B CD19 cells depletion and clinical effect was present in two cases only. Severe adverse events were present in two patients, including one fatal rituximab-related acute lung injury. CONCLUSION The anti-CD20 monoclonal antibody may be not effective in all pediatric cases of rapid post-transplant recurrence of nephrotic syndrome, and benefit/risk ratio must be carefully balanced on individual basis before taking the decision to use this protocol. WHAT IS KNOWN • nephrotic syndrome may recur immediately after renal transplantation • plasmapheresis combined with pharmacotherapy is used as rescue management • rituximab was reported as effective drug both in primary and post-transplant nephrotic syndrome What is New: • rituximab may not be effective is several cases of post-transplant nephrotic syndrome due to variety of underlying mechanisms of the disease, which may be or not be responsive to this drug • there may be no correlation between drug-induced depletion of specific B cells and clinical effect; this might suggest B-cell independent manner of rituximab action.
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Affiliation(s)
- Ryszard Grenda
- Department of Nephrology, Kidney Transplantation & Hypertension, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Wioletta Jarmużek
- Department of Nephrology, Kidney Transplantation & Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Jacek Rubik
- Department of Nephrology, Kidney Transplantation & Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Barbara Piątosa
- Histocompatibility Lab, The Children's Memorial Health Institute, Warsaw, Poland
| | - Sylwester Prokurat
- Department of Nephrology, Kidney Transplantation & Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
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Messina M, Gallo E, Mella A, Pagani F, Biancone L. Update on the treatment of focal segmental glomerulosclerosis in renal transplantation. World J Transplant 2016; 6:54-68. [PMID: 27011905 PMCID: PMC4801805 DOI: 10.5500/wjt.v6.i1.54] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 12/22/2015] [Accepted: 01/22/2016] [Indexed: 02/05/2023] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) represents one of the most severe glomerular diseases, with frequent progression to end-stage renal disease and a high rate of recurrence in renal allografts (30%-50%). Recurrent FSGS portends a negative outcome, with the hazard ratio of graft failure being two-fold higher then that of other glomerulonephritis. Two patterns of clinical presentations are observed: Early recurrence, which is characterized by massive proteinuria within hours to days after implantation of the renal graft, and late recurrence, which occurs several months or years after the transplantation. Many clinical conditions have been recognized as risk factors for recurrence, including younger age, rapid progression of the disease to end-stage renal disease on native kidneys, and loss of previous renal allografts due to recurrence. However, much less is known about the incidence and risk factors of the so-called “de novo” type of FSGS, for which sufferers are transplanted patients without disease on native kidneys; but, rapid development of allograft failure is frequently observed. Management of both forms is challenging, and none of the approaches proposed to date have been demonstrated as consistently beneficial or effective. In the present review we report an update on the available therapeutic strategies for FSGS in renal transplantation within the context of a critical overview of the current literature.
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Trachtman R, Sran SS, Trachtman H. Recurrent focal segmental glomerulosclerosis after kidney transplantation. Pediatr Nephrol 2015; 30:1793-802. [PMID: 25690943 DOI: 10.1007/s00467-015-3062-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 01/22/2015] [Accepted: 01/28/2015] [Indexed: 10/24/2022]
Abstract
Focal segmental glomerulosclerosis (FSGS) is an important cause of glomerular disease in children and adolescents and nearly 50 % of affected patients will progress to end-stage kidney disease over a 5 to 10-year period. Unfortunately, there is no established treatment for disease in the native kidney. Moreover, up to 55 % of patients develop recurrent disease after receiving a kidney transplant, with a substantially higher risk in patients who have already experienced recurrent disease in a prior transplant. A number of clinical and laboratory factors have been identified as risk factors for this complication. In addition, new investigations into podocyte biology and circulating permeability factors have shed light on the cause of recurrent the disease. While a number of novel therapeutic agents have been applied in the management of this problem, there still is no proven treatment. In this review, we summarize recent advances in the epidemiology, pathophysiology, and treatment of recurrent FSGS in pediatric patients who have received a kidney transplant.
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Affiliation(s)
- Rebecca Trachtman
- Division of Pediatric Nephrology, NYU Langone Medical Center, CTSI, Room #733 227 E 30th Street, New York, NY, 10016, USA
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9
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Thurman JM, Wong M, Renner B, Frazer-Abel A, Giclas PC, Joy MS, Jalal D, Radeva MK, Gassman J, Gipson DS, Kaskel F, Friedman A, Trachtman H. Complement Activation in Patients with Focal Segmental Glomerulosclerosis. PLoS One 2015; 10:e0136558. [PMID: 26335102 PMCID: PMC4559462 DOI: 10.1371/journal.pone.0136558] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 08/05/2015] [Indexed: 01/19/2023] Open
Abstract
Background Recent pre-clinical studies have shown that complement activation contributes to glomerular and tubular injury in experimental FSGS. Although complement proteins are detected in the glomeruli of some patients with FSGS, it is not known whether this is due to complement activation or whether the proteins are simply trapped in sclerotic glomeruli. We measured complement activation fragments in the plasma and urine of patients with primary FSGS to determine whether complement activation is part of the disease process. Study Design Plasma and urine samples from patients with biopsy-proven FSGS who participated in the FSGS Clinical Trial were analyzed. Setting and Participants We identified 19 patients for whom samples were available from weeks 0, 26, 52 and 78. The results for these FSGS patients were compared to results in samples from 10 healthy controls, 10 patients with chronic kidney disease (CKD), 20 patients with vasculitis, and 23 patients with lupus nephritis. Outcomes Longitudinal control of proteinuria and estimated glomerular filtration rate (eGFR). Measurements Levels of the complement fragments Ba, Bb, C4a, and sC5b-9 in plasma and urine. Results Plasma and urine Ba, C4a, sC5b-9 were significantly higher in FSGS patients at the time of diagnosis than in the control groups. Plasma Ba levels inversely correlated with the eGFR at the time of diagnosis and at the end of the study. Plasma and urine Ba levels at the end of the study positively correlated with the level of proteinuria, the primary outcome of the study. Limitations Limited number of patients with samples from all time-points. Conclusions The complement system is activated in patients with primary FSGS, and elevated levels of plasma Ba correlate with more severe disease. Measurement of complement fragments may identify a subset of patients in whom the complement system is activated. Further investigations are needed to confirm our findings and to determine the prognostic significance of complement activation in patients with FSGS.
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Affiliation(s)
- Joshua M. Thurman
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Maria Wong
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Brandon Renner
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Ashley Frazer-Abel
- Department of Pediatrics, National Jewish Health, Denver, Colorado, United States of America
| | - Patricia C. Giclas
- Department of Pediatrics, National Jewish Health, Denver, Colorado, United States of America
| | - Melanie S. Joy
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Diana Jalal
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Milena K. Radeva
- Cleveland Clinic Foundation, Cleveland, Ohio, United States of America
| | - Jennifer Gassman
- Cleveland Clinic Foundation, Cleveland, Ohio, United States of America
| | - Debbie S. Gipson
- Department of Pediatrics, CS Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Frederick Kaskel
- Department of Pediatrics, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Aaron Friedman
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Howard Trachtman
- Department of Pediatrics, NYU Langone Medical Center, NYU School of Medicine, New York, New York, United States of America
- * E-mail:
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10
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Lionaki S, Vlachopanos G, Georgalis A, Liapis G, Skalioti C, Zavos G, Boletis JN. Individualized scheme of immunoadsorption for the recurrence of idiopathic focal segmental glomerulosclerosis in the graft: a single center experience. Ren Fail 2015; 37:777-83. [PMID: 25715638 DOI: 10.3109/0886022x.2015.1015366] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To explore the role of immunoadsorption (IA) for the treatment of idiopathic focal segmental glomerulosclerosis (FSGS) recurrence in the renal allograft, if applied in a personalized manner. METHODS We studied patients with end-stage renal disease (ESRD) due to idiopathic FSGS, transplanted between 2001 and 2010. Patients with FSGS recurrence were treated with daily sessions of IA for the first week, followed by an every other day scheme and then individualized tapering until discontinuation. Complete remission was defined as a reduction of 24-h proteinuria to ≤ 0.5 g/day and partial remission as a reduction of 24-h proteinuria to 50% or more from baseline. RESULTS Of the 18 renal transplant recipients with ESRD due to idiopathic FSGS, 12 (66.7%) experienced disease recurrence in a mean time of 0.75 months post-transplantation (KTx), with a mean proteinuria of 8.9 g/day at the time of recurrence. The mean recipient age was 30.8 years; the mean donor age was 47.4 years, while living related donors provided the allograft in seven cases. Four of the patients received therapy with rituximab in addition to IA. During a mean time of follow-up of 48.3 months, seven patients (58.3%) achieved complete remission, and five (41.7%) partial remission. At the end of follow-up, eight patients (66.7%) had functioning grafts, being in sustained remission, in contrast to four patients (33.3%), who ended up in ESRD because of FSGS recurrence. CONCLUSIONS IA was shown efficacious in a small series of patients with recurrent FSGS in the graft. Renal function remained stable in eight of the 12 patients with FSGS recurrence.
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Affiliation(s)
- Sophia Lionaki
- a Department of Nephrology & Transplantation Unit , Laiko Hospital , Athens , Greece
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11
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Alkandari O, Nampoory N, Nair P, Atta A, Zakaria Z, Mossad A, Yagan J, Al-Otaibi T. Recurrent Focal Segmental Glomerulosclerosis and Abatacept: Case Report. EXP CLIN TRANSPLANT 2014; 14:456-9. [PMID: 25432003 DOI: 10.6002/ect.2014.0154] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Focal segmental glomerulosclerosis is a common cause of end-stage renal disease in children. Focal segmental glomerulosclerosis recurrence in renal transplants is a challenging disease, and can cause graft dysfunction and loss. Different therapies exist with varying responses, from complete remission to resistance to all modes of treatment. Abatacept was recently introduced as a treatment for primary focal segmental glomerulosclerosis in native kidneys and in recurrent disease after transplant. We present a pediatric case with immunosuppression-resistant primary NPHS2-negative focal segmental glomerulosclerosis recur-rence after renal transplant. The standard therapy for recurrent focal segmental glomerulosclerosis (rituximab, plasmapheresis, high-dose cyclosporine, and corticosteroids) was tried but failed to induce remission. Abatacept (10 mg/kg) was given at 0, 2, and 4 weeks (total, 3 doses) with no good response. We conclude that abatacept may work in patients with B7-1-positive focal segmental glomerulosclerosis recurrence and its efficacy is uncertain in disease with B7-1-negative or unknown staining status.
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Affiliation(s)
- Omar Alkandari
- From the Division of Pediatric Nephrology, Mubarak Al-Kabeer Hospital; and the Division of Nephrology, Hamid Al-Essa Organ Transplant Center, Sabah Health Region, Shuwaikh, Kuwait
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12
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Rieder F, de Bruyn JR, Pham BT, Katsanos K, Annese V, Higgins PDR, Magro F, Dotan I. Results of the 4th scientific workshop of the ECCO (Group II): markers of intestinal fibrosis in inflammatory bowel disease. J Crohns Colitis 2014; 8:1166-78. [PMID: 24726695 DOI: 10.1016/j.crohns.2014.03.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 03/12/2014] [Accepted: 03/15/2014] [Indexed: 02/08/2023]
Abstract
The fourth scientific workshop of the European Crohn's and Colitis Organization (ECCO) focused on intestinal fibrosis in inflammatory bowel disease (IBD). The objective was to better understand basic mechanisms and markers of intestinal fibrosis as well as to suggest new therapeutic targets to prevent or treat fibrosis. The results of this workshop are presented in three separate manuscripts. This section describes markers of fibrosis in IBD, identifies unanswered questions in the field and provides a framework for future studies addressing the unmet needs in the field of intestinal fibrosis.
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Affiliation(s)
- Florian Rieder
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA; Department of Gastroenterology & Hepatology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Jessica R de Bruyn
- Academic Medical Center Amsterdam, Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands.
| | - Bao Tung Pham
- Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, The Netherlands.
| | - Konstantinos Katsanos
- Department of Gastroenterology, University Hospital of Ioannina, Medical School of Ioannina, Greece.
| | - Vito Annese
- Division of Gastroenterology, University Hospital Careggi, Florence, Italy.
| | - Peter D R Higgins
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA.
| | - Fernando Magro
- Department of Pharmacology & Therapeutics, Institute for Molecular and Cell Biology, Faculty of Medicine University of Porto, Porto, Portugal; Department of Gastroenterology, Hospital de Sao Joao, Porto, Portugal.
| | - Iris Dotan
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Straatmann C, Kallash M, Killackey M, Iorember F, Aviles D, Bamgbola O, Carson T, Florman S, Vehaskari MV. Success with plasmapheresis treatment for recurrent focal segmental glomerulosclerosis in pediatric renal transplant recipients. Pediatr Transplant 2014; 18:29-34. [PMID: 24266922 DOI: 10.1111/petr.12185] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 11/30/2022]
Abstract
FSGS recurs in approximately 30% of transplanted kidneys and may lead to graft loss. We retrospectively examined the efficacy of early and intensive PP without additional IS in pediatric kidney transplant patients with recurrent FSGS at our center. Seven of 24 patients (29%) had nephrotic proteinuria and histologic evidence of FSGS recurrence within 1-5 days post-transplantation. PP was initiated early after transplantation and initially performed daily until sustained decline in proteinuria. PP frequency was then individually tapered according to proteinuria. Recurrent FSGS in all seven patients responded to a four- to 32-wk course of PP. Two of seven patients had a second recurrence of FSGS, and both recurrences remitted after an additional 3-6 wk of PP. Median observation period was 4.5 yr (0.8-16.3 yr). Complete remission of recurrent FSGS has been sustained in all seven patients, and all patients have stable graft function with recent plasma creatinine <1.5 mg/dL in six of seven patients. Most recent urine protein/creatinine is 0.13-0.61 mg/mg in six of seven patients. One patient has heavy proteinuria secondary to chronic allograft nephropathy 16 yr post-transplant. Intensive and prolonged PP, when initiated early in the post-operative period, is effective in treating recurrent FSGS and preventing graft loss without the use of additional immunosuppressants.
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Affiliation(s)
- Caroline Straatmann
- Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
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Strassheim D, Renner B, Panzer S, Fuquay R, Kulik L, Ljubanović D, Holers VM, Thurman JM. IgM contributes to glomerular injury in FSGS. J Am Soc Nephrol 2013; 24:393-406. [PMID: 23393315 DOI: 10.1681/asn.2012020187] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Glomerular IgM and C3 deposits frequently accompany idiopathic FSGS and secondary glomerulosclerosis, but it is unknown whether IgM activates complement, possibly contributing to the pathogenesis of these diseases. We hypothesized that IgM natural antibody binds to neoepitopes exposed in the glomerulus after nonimmune insults, triggering activation of the complement system and further injury. We examined the effects of depleting B cells, using three different strategies, on adriamycin-induced glomerulosclerosis. First, we treated wild-type mice with an anti-murine CD20 antibody, which depletes B cells, before disease induction. Second, we evaluated adriamycin-induced glomerulosclerosis in Jh mice, a strain that lacks mature B cells. Third, we locally depleted peritoneal B cells via hypotonic shock before disease induction. All three strategies reduced deposition of IgM in the glomerulus after administration of adriamycin and attenuated the development of albuminuria. Furthermore, we found that glomerular IgM and C3 were detectable in a subset of patients with FSGS; C3 was present as an activation fragment and colocalized with glomerular IgM, suggesting that glomerular IgM may have bound a cognate ligand. Taken together, these results suggest that IgM activates the complement system within the glomerulus in an animal model of glomerulosclerosis. Strategies that reduce IgM natural antibody or that prevent complement activation may slow the progression of glomerulosclerosis.
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Affiliation(s)
- Derek Strassheim
- Department of Medicine, School of Medicine, University of Colorado Denver, Aurora, Colorado 80045, USA
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15
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Cravedi P, Kopp JB, Remuzzi G. Recent progress in the pathophysiology and treatment of FSGS recurrence. Am J Transplant 2013; 13:266-74. [PMID: 23312002 PMCID: PMC3558619 DOI: 10.1111/ajt.12045] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 11/05/2012] [Accepted: 11/06/2012] [Indexed: 01/25/2023]
Abstract
Focal segmental glomerulosclerosis (FSGS) is a glomerular disease characterized by proteinuria, frequent progression to end-stage renal disease, and recurrence after kidney transplantation in ∼25% of patients, which negatively impacts long-term allograft survival. Experimental studies suggest that abnormalities in T and, possibly, B cells may represent one initial pathogenic trigger, leading to podocyte injury and progressive loss. New data also support the existence of circulating permeability factors able to damage the podocytes, but no single molecule has been consistently identified as the causal pathogenic element in FSGS recurrence. Unfortunately, major progress from mechanistic studies has not translated into substantial advancements in patient treatment, with plasmapheresis (PP) and high doses of cyclosporine (CsA) remaining the mainstays of therapy. Despite consistent experimental and clinical evidence that treatment of proteinuria slows renal function decline in proteinuric nephropathies, maximal use of antiproteinuric agents such as renin angiotensin system antagonists is not routine in the management of FSGS recurrence. More recently, encouraging results have been reported with anti-CD20 depleting antibody rituximab, but further studies are needed to establish its safety/efficacy profile.
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Affiliation(s)
- Paolo Cravedi
- Mario Negri Institute for Pharmacological Research, Clinical Research Center for Rare Diseases “Aldo e Cele Dacco”, Villa Camozzi, Ranica, Bergamo, Italy
| | - Jeffrey B. Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Giuseppe Remuzzi
- Mario Negri Institute for Pharmacological Research, Clinical Research Center for Rare Diseases “Aldo e Cele Dacco”, Villa Camozzi, Ranica, Bergamo, Italy,Unit of Nephrology, Azienda Ospedaliera Ospedali Riuniti di Bergamo, Bergamo, Italy
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16
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Kumar J, Shatat IF, Skversky AL, Woroniecki RP, Del Rio M, Perelstein EM, Johnson VL, Mahesh S. Rituximab in post-transplant pediatric recurrent focal segmental glomerulosclerosis. Pediatr Nephrol 2013; 28:333-8. [PMID: 23052653 PMCID: PMC3541458 DOI: 10.1007/s00467-012-2314-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 08/03/2012] [Accepted: 08/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Focal segmental glomerulosclerosis (FSGS) recurs in 20-40 % of allografts. Plasmapheresis (TPE) has been one of the mainstays of treatment with variable results. Rituximab (RTX), a monoclonal antibody to the protein CD20, is being used for treatment of recurrent FSGS (recFSGS) but pediatric experience is limited. METHODS We conducted a retrospective review of eight patients with recFSGS, treated with RTX (1-4 doses) after having minimal response to TPE. Complete response was defined as a decrease in urine protein creatinine ratio (Up/c) to less than 0.2 and partial response was a decrease in Up/c ratio by 50 % of baseline and in the sub-nephrotic range (U p/c <2). RESULTS Complete response was seen in two of eight patients, and partial response was seen in four of eight patients. Two patients had no response. At last follow-up, all the partial responders had sub-nephrotic range proteinuria (Up/c ratios ranging from 0.29 to 1.6). Delayed response, up to 9 months post-RTX, was also seen in some of the patients. Significant complications such as rituximab-associated lung injury (RALI), acute tubular necrosis, and central nervous system(CNS) malignancy were also observed in our case series. CONCLUSIONS Rituximab can be used with caution as a treatment for recFSGS. Efficacy is variable from none to complete response. Even partial reduction in proteinuria is of benefit in prolonging the life of the allograft. Long-term, multicenter studies are needed to prove its sustained efficacy in those who respond and to monitor for serious adverse effects.
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Affiliation(s)
- Juhi Kumar
- Weill Cornell Medical College, Helmsley Towers 3, Box 176, New York, NY 10021, USA.
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Cantarovich D, Focosi D, Boggi U. Fifth kidney transplantation in a patient with focal segmental glomerulosclerosis. Transpl Int 2013; 26:e19-21. [PMID: 23279073 DOI: 10.1111/tri.12036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Recurrent focal segmental glomerulosclerosis: a discrete clinical entity. Int J Nephrol 2012; 2012:246128. [PMID: 22288013 PMCID: PMC3263622 DOI: 10.1155/2012/246128] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 10/04/2011] [Accepted: 10/04/2011] [Indexed: 12/01/2022] Open
Abstract
Focal segmental glomerulosclerosis refers to a set of particular histopathologic lesions in which steroid-resistant podocyte injury leads to patchy adhesions between the glomerular tuft and Bowman's capsule, followed by progressive glomerulosclerosis and proteinuric renal failure. Because of the nonspecific nature of this lesion, it has been difficult to classify the various forms of primary nephrotic syndrome in children. However, with the recognition of hereditary FSGS caused by mutations podocyte slit diaphragm genes, it is increasingly clear that the steroid-resistant form of FSGS that recurs in the renal allografts (R-FSGS) constitutes a distinct clinical entity. Capitalizing on recent studies in which patients have been screened for slit diaphragm gene mutations, this review focuses on the natural history and pathogenesis of R-FSGS.
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The factors that may predict response to rituximab therapy in recurrent focal segmental glomerulosclerosis: a systematic review. J Transplant 2011; 2011:374213. [PMID: 22174985 PMCID: PMC3235904 DOI: 10.1155/2011/374213] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 10/11/2011] [Indexed: 01/25/2023] Open
Abstract
Recurrence of FSGS occurs in 30–40% of allografts. Therapies for recurrence are not well established. We retrieved all published reports depicting kidney transplant recipients with focal segmental glomerulosclerosis (FSGS) recurrence, treated with rituximab, to determine factors associated with treatment response. We found 18 reports of 39 transplant recipients who received rituximab. By univariate analysis for two outcomes (no response versus any response), fewer rituximab infusions and normal serum albumin at recurrence were associated with treatment response. For 3 outcomes (no response, partial and complete remission), male gender, fewer rituximab infusions, shorter time to rituximab treatment, and normal serum albumin were associated with remission. Multivariate analysis for both models revealed that normal serum albumin at FSGS recurrence and lower age at transplant were associated with response.
Rituximab for recurrence of FSGS may be beneficial for only some patients. A younger age at transplant and normal serum albumin level at recurrence diagnosis may predict response.
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Kiffel J, Rahimzada Y, Trachtman H. Focal segmental glomerulosclerosis and chronic kidney disease in pediatric patients. Adv Chronic Kidney Dis 2011; 18:332-8. [PMID: 21896374 DOI: 10.1053/j.ackd.2011.03.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 03/07/2011] [Accepted: 03/25/2011] [Indexed: 11/11/2022]
Abstract
Focal segmental glomerulosclerosis (FSGS) is one of the most common forms of acquired glomerular disease leading to end-stage kidney disease. Its incidence is rising around the world. There is no proven therapy for those patients who do not respond to corticosteroids and it can recur in 20% to 25% of patients who receive a kidney transplant. The disease can be primary, or it can be secondary to various conditions including vesicoureteral reflux, obesity, medications, and infections. Recent advances have demonstrated the important role of genetic mutations in podocyte proteins as a cause of FSGS. There is an urgent need for randomized clinical trials to develop safe and effective therapy for FSGS that occurs in the native or transplanted kidney.
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