Successful Treatment of Focal Segmental Glomerulosclerosis Recurrence in a Second Kidney Transplant Patient: A Case Report

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

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Biologics in steroid resistant nephrotic syndrome in childhood: review and new hypothesis-driven treatment

Nephrotic syndrome affects about 2-7 per 100,000 children yearly and accounts for less than 15% of end stage kidney disease. Steroids still represent the cornerstone of therapy achieving remission in 75-90% of the cases The remaining part result as steroid resistant nephrotic syndrome, characterized by the elevated risk of developing end stage kidney disease and frequently presenting disease recurrence in case of kidney transplant. The pathogenesis of nephrotic syndrome is still far to be elucidated, however, efficacy of immune treatments provided the basis to suggest the involvement of the immune system in the pathogenesis of the disease. Based on these substrates, more immune drugs, further than steroids, were administered in steroid resistant nephrotic syndrome, such as antiproliferative and alkylating agents or calcineurin inhibitors. However, such treatments failed in inducing a sustained remission. In last two decades, the developments of monoclonal antibodies, including the anti-CD20 rituximab and inhibitor of B7-1 abatacept, represented a valid opportunity of treatment. However, also the effectiveness of biologics resulted limited. We here propose a new hypothesis-driven treatment based on the combining administration of rituximab with the anti-CD38 monoclonal antibody daratumumab (NCT05704400), sustained by the hypothesis to target the entire B-cells subtypes pool, including the long-lived plasmacells.

Management of recurrent focal segmental glomerulosclerosis (FSGS) post renal transplantation

BACKGROUND

One of the common GN causing ESKD is focal segmental glomerulosclerosis (FSGS). Recurrence of FSGS post-transplantation can lead to graft loss. Data on management either prophylactically or once recurrence occurs are limited. This review article aims to assess the effective management of patients with FSGS recurrence post-transplantation, looking mainly at recurrence post prophylactic treatment and remission in case of treatment post recurrence.

METHODS

Twenty-three studies were included using the search MeSH terms "FSGS" "recurrence" "adults" "transplantation" "treatment". Search engines used were Pubmed, clinical key, Scopus and Cochrane library. Inclusion criteria were articles covered adult patients with recurrent FSGS post renal transplantation, treatment with rituximab and plasmapheresis, and articles published from 2000 tt2021. Excluded articles were paediatric population, studies with no reported outcomes of the treatment of FSGS, and Patients who received stem cell transplantation or galactose therapy.

RESULTS

Prophylactic PP did not show a reduction in recurrence of FSGS in 2/3 studies. Prophylactic rituximab was shown to reduce recurrence of FSGS in one-study and case reports. Treatment of recurrent FSGS with PP showed responses ranging from 41% to 100%. Only one study did not show improvement with PP use as treatment having a 27% remission. Treatment with rituximab showed variable results, with reports showing remission ranging from 57% to 100%. Whereas other reports showing no response at all. PP prescription reporting was variable. One study suggested intensified PP regimen while in most other studies PP was guided by the response reflected by the reduction of proteinuria.

DISCUSSION

Reviewing the treatment of recurrent FSGS is crucial, as there no consensus on treating FSGS as the disease is not very common in the adult population. The evidence of different modalities is based on small cohort studies. This paper supports the use of PP and RTX as treatment of recurrent FSGS.

CONCLUSIONS

In conclusion, PP and RTX are the main modalities to treat recurrent FSGS with varying response rates. Prophylactic PP does not play a role in preventing recurrent FSGS. Prophylactic rituximab might play a role in preventing FSGS post-transplantation. PP and RTX, when used as a treatment, show variable response rates. Larger RCTs are needed to have a strong level of evidence to base our clinical management on.