Use of rituximab and plasma exchange in treatment and prophylaxis of recurrent FSGS

Focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome and renal failure, requiring transplantation. However, FSGS can often recur after transplantation resulting in graft failure. The most used therapeutic intervention for rFSGS is plasma exchange (PE), with variable success. Recently, rituximab has found increasing use in both treatment and prevention of recurrent FSGS.

We undertook a systematic review of therapeutic ± preventative plasma exchange, rituximab or a combination of both for recurrent FSGS. Studies published between 2017 and 2024 were included, to reflect the most contemporary clinical practice.

Twenty-seven studies with a total of 475 patients received treatment for recurrence post-transplantation and/or for prevention of recurrent FSGS. Of 221 patients who received plasma exchange on its own as therapy, 156 (71%) achieved either complete or partial remission. Rituximab alone was used in only four patients (75% remission rate), while 67% achieved remission with a combination of both. One hundred and forty-two patients received pre/peri-transplantation treatment to prevent recurrence in the graft. Fifty-one patients (36%) experienced recurrence despite prophylaxis. Recurrence rates were 35% with plasma exchange alone and 38% with rituximab alone.

We conclude that rituximab did not add significant benefit to plasma exchange when used as initial therapeutic intervention in post-transplant recurrent FSGS. The modest benefit of prophylactic therapies highlights the need for risk stratification to identify patients most likely to benefit from such interventions. Larger prospective studies with standardized approaches to treatment are essential in improving outcomes in rFSGS.