Successful management of post-transplant focal segmental glomerulosclerosis with therapeutic plasma exchange and rituximab

Abstract

Background

Post-transplant focal segmental glomerulosclerosis (FSGS) is associated with renal allograft loss. Currently, optimal treatment remains controversial.

Methods

The aim of our study was to examine the efficacy and safety of therapeutic plasma exchange (TPE), and rituximab (RTX), in the management of post-transplant FSGS. The treatment protocol consisted of RTX and monthly cycles of 5 plasma exchanges for 6 months. We treated 10 transplant recipients with biopsy-proven post-transplant FSGS. Lastly, we compared the studied group to a historic control group of nine patients with post-transplant FSGS.

Results

9 out of 10 patients achieved remission after the conclusion of treatment (4 complete and 5 partial), while 1 patient did not respond to treatment. During the follow-up period, there was one graft loss and one patient died while in remission from unrelated complications. There was a significant reduction in mean uPCR between diagnosis (517.4 ± 524.2 mg/mmol) and last follow-up (87 ± 121.6 mg/mmol) in the patients with sustained remission (p = 0.026). There was no significant decline in eGFR in the eight relapse-free responders at the end of follow-up. (54.4 ± 16.7 from 49.8 ± 20.4 ml/min) (p = 0.6) An increased response rate to the combined TPE and RTX treatment was demonstrated, when compared to a historic control group of nine patients with post-transplant FSGS, as only five out of nine patients achieved remission (two complete and three partial) in that group.

Conclusions

In this study, treatment with TPE and RTX appears to be safe, well tolerated and effective in the management of patients with post-transplant FSGS.

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Abbreviations

FSGS:

Focal segmental glomerulosclerosis

uPCR:

Urine protein creatinine ratio

eGFR:

Estimated glomerular filtration rate

EM:

Electron microscopy

FPE:

Foot process effacement

MMF:

Mycophenolate mofetil

TPE:

Therapeutic plasma exchange

ESRD:

End-stage renal disease

RTX:

Rituximab

HAS:

Human albumin solution

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Corresponding author

Correspondence to Konstantinos Koutroutsos.

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Conflict of interest

All the authors have declared no competing interest.

Research involving Human Participants and/or Animals

This article does not contain any studies with human participants or animals performed by any of the authors. This was a retrospective review meeting the criteria for a service evaluation study and hence did not require approval from a Research Ethics Committee. This study was approved by the Departmental Transplant Research Group. This therapeutic protocol for the management of post-transplant FSGS was introduced in our institution in 2011 and became the standard treatment for this clinical condition as approved by the Transplant Clinical and Research Group in our Centre. Our retrospective study is in compliance with the Helsinki Declaration.

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All patients gave their consent for treatment and received standard care according to our accepted unit protocol.

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Koutroutsos, K., Charif, R., Moran, L. et al. Successful management of post-transplant focal segmental glomerulosclerosis with therapeutic plasma exchange and rituximab. Clin Exp Nephrol 23, 700–709 (2019). https://doi.org/10.1007/s10157-019-01690-0

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Keywords

  • Rituximab
  • Transplantation
  • Focal segmental glomerulosclerosis
  • Therapeutic plasma exchange