Rituximab and Therapeutic Plasma Exchange in Recurrent Focal Segmental Glomerulosclerosis Postkidney Transplantation

Background Focal segmental glomerulosclerosis (FSGS) is a common cause of end stage renal disease (ESRD) with a high rate of recurrence after kidney transplantation. Several factors such as white race, rapid progression, and previous allograft failure due to recurrence were found to be risks of recurrence. Data are limited on the benefits of rituximab and/or therapeutic plasma exchange (TPE) in preventing recurrence. In this study, we sought to assess the efficacy of rituximab and TPE for the prevention and treatment of recurrent FSGS post kidney transplantation. Methods We enrolled 66 patients with FSGS in this prospective observational study and followed their outcomes. Patients with high risk for recurrence received preventative therapy with TPE and/or rituximab. Results Twenty three of the thirty seven (62%) who received preventative therapy developed recurrence compared to fourteen recurrences out of the twenty seven (51%) who did not receive any therapy (p=0.21). There was a trend for less relapse when rituximab was used as a therapy for recurrent FSGS, (6/22 versus 9/18, p=0.066). We utilized a clinical score of 5 values to assess the prediction of FSGS recurrence. A score of 3 or more had a predictive Receiver Operating Characteristic (ROC) curve of 0.72. Treatment with TPE and/or rituximab resulted in better allograft survival than historical studies. Allograft failure due to recurrent FSGS occurred in only 6 patients (9%). Conclusion Preventative therapies do not decrease the recurrence rate of recurrent FSGS. However, prompt treatment of recurrence with these therapies may result in improved outcomes. Corresponding Author: Nada Alachkar, MD, 600 Wolfe St. Brady 502, Baltimore, MD. Email: nalachk1@jhmi.edu Authorship Page: Sami Alasfar: data collection, data analysis and interpretation, drafting the article Dany Matar: data collection Robert A Montgomery: critical revision of the article Niraj Desai: critical revision of the article Bonnie Lonze: critical revision of the article Vikas Vujjini: data collection Michelle M. Estrella: critical revision of the article John Manllo Dieck: data collection, critical revision of the article Gebran Khneizer: data collection Sanja Sever: critical revision of the article Jochen Reiser: critical revision of the article Nada Alachkar: design of the work, data collection, data analysis and interpretation, drafting the article, final approval of the version to be published Disclosures: JR and SS are cofounders and stock holders of Trisaq, a biotechnological company developing novel therapeutics for chronic kidney diseases and FSGS, and have pending and issued patents in the therapeutic and diagnostic space regarding kidney diseases. Sources of support: NIH R01DK101350-04, Nada Alachkar Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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