Are there special issues in patients with Focal segmental glomerulosclerosis with respect to kidney transplantation?
Primary FSGS recurs in 10% of initial kidney allografts. Proteinuria may develop within minutes of allograft implantation.
In this setting, circulating factors in the recipient cause acute glomerular capillary permeability, podocyte foot process effacement, and subsequent glomerulosclerosis.
If uncontrolled, recurrent FSGS reduces allograft survival. Patients with a history of rapid FSGS recurrence have a very high risk for FSGS recurrence in subsequent kidney transplants.
Patients with FSGS may receive an allograft from either deceased donors or living related donors.
Concerns about using that living related donors may have increased risk of recurrence have not born out.
Plasmapheresis can be used in the immediate pretransplant and posttransplant period in an attempt to remove the substances responsible for inducing proteinuria and recurrent FSGS.
Rituximab has been used in the setting of posttransplant FSGS recurrence. These approaches have not been evaluated in randomized studies, but case series suggest they may be helpful in preventing and treating early FSGS recurrence.
However, the addition of these therapies to standard kidney transplant induction immunosuppression leads to profound immunocompromised state increasing the risk for life-threatening infections.
