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Dharnidharka VR, Scobell RR, Kallash M, Davies AJG, Marchesani N, Maltenfort MG, Walther L, Kelton M, Bock M, Blanchette E, Stone HK, Gluck C, Hullekes F, Riella LV, Smoyer WE, Mitsnefes M, Dixon BP, Flynn JT, Somers MJG, Forrest CB, Furth S, Denburg MR. Clinical characteristics and favorable treatment responses of recurrent focal segmental glomerulosclerosis or steroid-resistant nephrotic syndrome in children after kidney transplantation. Pediatr Nephrol 2024; 39:3317-3331. [PMID: 39001911 DOI: 10.1007/s00467-024-06452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Recurrence of focal segmental glomerulosclerosis (FSGS) or steroid-resistant nephrotic syndrome (SRNS) after kidney transplant leads to significant morbidity and potentially earlier allograft loss. To date however, reported rates, risk factors and treatment outcomes have varied widely. METHODS We applied computational phenotypes to a multicenter aggregation of electronic health records data from 7 large pediatric health systems in the USA, to identify recurrence rates, risk factors, and treatment outcomes. We refined the data collection by chart review. RESULTS From > 7 million patients, we compared children with primary FSGS/SRNS who received a kidney transplant between 2009 and 2020 and who either developed recurrence (n = 67/165; 40.6%) or did not (n = 98/165). Serum albumin level at time of transplant was significantly lower and recipient HLA DR7 presence was significantly higher in the recurrence group. By 36 months post-transplant, complete remission occurred in 58.2% and partial remission in 17.9%. Through 6 years post-transplant, no remission after recurrence was associated with an increased risk of allograft loss over time (p < 0.0001), but any remission showed similar allograft survival and function decline to those with no recurrence. Since treatments were used in non-random fashion, using spline curves and multivariable non-linear analyses, complete + partial remission chance was significantly higher with greater plasmapheresis sessions, CTLA4-Ig doses or LDL-apheresis sessions. Only treatment with anti-CD20, CTLA4-Ig agents, or LDL-apheresis sessions were associated with complete remission. Excluding 25 patients with mutations did not significantly change our results. CONCLUSIONS Our contemporary high-risk cohort had higher favorable response rates than most prior reports, from combinations of agents.
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Affiliation(s)
- Vikas R Dharnidharka
- Washington University School of Medicine and St. Louis Children's Hospital, Room NWT 10-119, CB 8116, 660 South Euclid Avenue, St. Louis, MO, 63110, USA.
| | | | - Mahmoud Kallash
- Department of Pediatrics, The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | | | | | | | - Leslie Walther
- Washington University School of Medicine and St. Louis Children's Hospital, Room NWT 10-119, CB 8116, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Megan Kelton
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Margret Bock
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Eliza Blanchette
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hillarey K Stone
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | - William E Smoyer
- Department of Pediatrics, The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Mark Mitsnefes
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | - Susan Furth
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle R Denburg
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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