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Early use of plasmapheresis for recurrent post-transplant FSGS
Madhura Pradhan1, Julie Petro, Joanne Palmer
1Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA. pradhan@email.chop.edu
Insights
Early plasmapheresis effectively treats recurrent focal segmental glomerulosclerosis (FSGS) after kidney transplant. Prompt treatment within one day of recurrence led to remission and preserved graft function in most pediatric patients, preventing graft loss.
Area of Science:
- Nephrology
- Transplantation Immunology
- Internal Medicine
Background:
- Recurrence of focal segmental glomerulosclerosis (FSGS) in kidney allografts is a significant cause of graft loss.
- Management strategies for post-transplant FSGS recurrence remain challenging.
- Plasmapheresis is a potential therapeutic option for recurrent FSGS.
Purpose of the Study:
- To evaluate the efficacy of early plasmapheresis in children with recurrent FSGS post-kidney transplantation.
- To determine the impact of treatment timing on outcomes in recurrent FSGS.
Main Methods:
- Retrospective analysis of pediatric patients with biopsy-proven FSGS who underwent kidney transplantation.
- Identification of patients with recurrent FSGS based on elevated urine protein/creatinine ratios post-transplant.
- Treatment with plasmapheresis initiated at different time points following recurrence diagnosis.
Main Results:
- Six of 18 pediatric patients experienced recurrent FSGS.
- Four patients treated within 1 day of recurrence achieved remission after 5-13 plasmapheresis sessions, maintaining good graft function long-term (22-53 months).
- Two patients treated later (7 and 17 days post-proteinuria onset) experienced graft loss due to complications including acute tubular necrosis and rejection.
Conclusions:
- Early institution of plasmapheresis (within 1 day of recurrence) is an effective strategy for managing post-transplant FSGS recurrence in children.
- Timely treatment is crucial for achieving remission and preserving kidney allograft function.
- Delayed treatment is associated with a higher risk of graft loss.
Abstract:
Recurrence of focal segmental glomerulosclerosis (FSGS) in an allograft is a challenging clinical situation because it frequently results in graft loss. We report our experience with early use of plasmapheresis in recurrent FSGS. Of the 18 (33%) children with biopsy-proven FSGS (in their native kidneys) transplanted at our institution, 6 had recurrence (elevated urine protein/creatinine ratios) post transplant and were treated with plasmapheresis. Patients who received treatment within 1 day of the recurrence (4/6) went into remission after 5-13 plasmapheresis treatments, within 5-27 days of starting treatment. Patients who did not respond to plasmapheresis (2/6) were treated 7 and 17 days after onset of proteinuria; 1 of these had acute tubular necrosis and acute rejection leading to graft loss and the other developed acute rejections, ongoing proteinuria, and subsequent graft loss. All 4 patients who went into remission have maintained good graft function, 22-53 months post transplant. In our experience early institution of plasmapheresis for recurrent post-transplant proteinuria in FSGS is effective.