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Kidney Clinical - Part 2

Tuesday March 29, 2022 - 17:00 to 18:10


420.5 Re-transplantation in Pediatric Patients with Failure of Primary Transplant due to Recurrent Focal Segmental Glomerulosclerosis. A Pediatric Nephrology Research Consortium Study.

Samhar Al-Akash, United States

Medical Director, Dialysis and Transplantation
Driscoll Children's Hospital


Re-transplantation in Pediatric Patients with Failure of Primary Transplant due to Recurrent Focal Segmental Glomerulosclerosis. A Pediatric Nephrology Research Consortium Study

Samhar Al-Akash1, David K. Hooper2, Aesha Maniar3, Christine B. Sethna3, Pamela Singer3, Avram Z. Traum4, Priya Verghese5, Rouba Garro6, Margaret Kamel6, Elizabeth Kotzen7, Daniel Ranch8, Weiwen Shih9, Namrata Jain10.

1Nephrology, Driscoll Children's Hospital, CORPUS CHRISTI, TX, United States; 2Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; 3Pediatrics, Cohen Children's Medical Center, New Hyde Park, NY, United States; 4Pediatric Nephrology, Boston Children's Hospital, Boston, MA, United States; 5Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, United States; 6Pediatric Nephrology, Emory University School of Medicine, Atlanta, GA, United States; 7Nephrology, University of North Carolina Chapel Hill, Chapel Hill, NC, United States; 8Pediatric Nephrology, University of Texas Health Sciences Center, San Antonio, TX, United States; 9Nephrology, C.S. Mott Children's Hospital, Ann Arbor, MI, United States; 10Pediatric Nephrology, Hackensack University Medial Center, Hackensack, NJ, United States

Pediatric Nephrology Research Consortium.

Introduction: Recurrent focal and segmental glomerulosclerosis (FSGS) in kidney transplant recipients is associated with lower graft survival and increased morbidity. There are limited data to guide the decision to re-transplant patients with transplant failure due to FSGS recurrence. We aimed to evaluate outcomes in patients re-transplanted after having initial graft failure due to recurrent FSGS, and to study physician attitudes and practice patterns.
Methods: Retrospective data from 10 centers was collected on 20 patients transplanted between January 1997 and September 2018. A survey was sent to nephrologist members of the Pediatric Nephrology Research Consortium.
Results: Mean patient age (years) was 9.8±4.8 at first transplant, and 15.9±4.9 at re-transplantation. Pre-transplant plasmapheresis was used in 1 (5.3%) primary transplant vs. 7 (38.9%) re-transplants (p= 0.03). Nephrotic syndrome recurred in 12 patients (60%) after re-transplantation, and was severe in 21.1% vs 64.7% after first transplant (p= 0.04) (Figure 1). Graft survival was significantly higher in the second transplant (p 0.009), with 70% having functioning grafts at a median of 25.2 months (Figure 2). 31 physicians from 21 centers completed the survey, 94% indicated they would re-transplant such patients, 44.4% preferred a minimum waiting period before re-transplantation, 36.4% preferred living donors, and 22.2% indicated having protocols for re-transplantation at their centers.
Conclusions: Consideration for re-transplantation is high among pediatric nephrologists. Pre-transplant plasmapheresis was more frequent in re-transplanted patients. Nephrotic syndrome recurrence was less severe, with better graft survival. More data and a larger population are necessary to further evaluate outcome determinants and best practices in this special population.


[1] 1. Koh LJ, Martz K, Blydt-Hansen TD. Risk factors a ssociated with graft failure in pediatric kidney transplant recipients with focal and segmental glomerulosclerosis. Pediatr Transplant 2019; 23:e13469.
[2] 2. Cochat P, Frague S, Mestrallet G, et al. Disease recurrence in pediatric renal transplantation. Pediatr Nephrol 2009; 24: 2097-2108.
[3] 3. Trachtman R, Sran SS, Trachtman H. Recurrent focal segmental glomerulosclerosis after kidney transplantation. Pediatr Nephrol 2015; 30(10): 1793-802.
[4] 4. Allen PJ, Chadban SJ, Craig JC, et al. Recurrent glomerulonephritis after kidney transplantation: risk factors and allograft outcomes. Kidney Int 2017; 92(2): 461-469.
[5] 5. Cosio FG and Cattran DC. Recent advances in our understanding of recurrent primary glomerulonephritis after kidney transplantation. Kidney Int 2017; 91(2): 304-314.
[6] 6. Briganti EM, Russ GR, McNeil JJ, et el. N Eng J Med 2002; 347(2): 103-9
[7] 7. Jungraithmayr TC, Hofer K, Cochat P, et al. Screening for NPHS2 mutations may help predict FSGS recurrence after transplantation. J Am Soc Nephrol 2011; 22(3): 579-85.
[8] 8. Schwartz GJ, Work DF. Measurement and estimation of GFR in children and adolescents. Clin J Am Soc Nephrol 2009; 4: pp. 1832-1843.
[9] 9. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150(9): 604-12.
[10] 10. Canaud G, Zuber J, Sberro R, at al. Intensive and prolonged treatment of focal and segmental glomerulosclerosis recurrence in adult kidney transplant recipients: a pilot study. Am J
[11] 11. Dall’Amico R, Ghiggeri G, Carraro M, et al. Prediction and treatment of recurrent focal segmental glomerulosclerosis after renal transplantation in children. Am J Kidney Dis 1999; 34(6): 1048-55.
[12] 12. Ponticelli C. Recurrence of focal segmental glomerular sclerosis (FSGS) after renal transplantation. Nephrol Dial Transplant 2010; 25(1): 25-31.
[13] 13. Kashgary A, Sontrop JM, Li L, et al. The role of plasma exchange in treating post-transplant focal segmental glomerulosclerosis: A systematic review and meta-analysis of 77 case-reports and case-series. BMC Nephrol 2016; 17(1): 104
[14] 14. Verghese PS, Rheault MN, Jackson S, et al. The effect of peri-transplant plasmapheresis in the prevention of recurrent FSGS. Pediatr Transplant. 2018; 22:e13154.
[15] 15. Gohh RY, Yango AF, Morrissey PE. Preemptive plasmapheresis and recurrence of FSGS in high-risk renal transplant recipients. Am J Transplant 2005; 5(12): 2907-12.
[16] 16. Messina M, Gallo E, Mella A, et al. Update on the treatment of focal segmental glomerulosclerosis in renal transplantation. World J Transplant 2016; 6(1): 54-68.
[17] 17. Straatmann C, Kallash M, Killackey M, et al. Success with plasmapheresis treatment for recurrent focal segmental glomerulosclerosis in pediatric renal transplant recipients. Pediatr Transplant 2014; 18: 29–34.
[18] 18. Weber LT, Tönshoff B, Grenda R, et al. Clinical practice recommendations for recurrence of focal and segmental glomerulosclerosis/steroid-resistant nephrotic syndrome. Pediatr Transplant 2020; 00: e13955
[19] 19. Savin VJ, Sharma R, McCarthy ET, et al. Circulating factor associated with increased glomerular permeability to albumin in recurrent focal segmental glomerulosclerosis. N Eng J Med 1996; 334(14): 878-83.
[20] 20. Sharma M, Sharma R, McCarthy ET, Savin VJ. "The FSGS factor:" enrichment and in vivo effect of activity from focal segmental glomerulosclerosis plasma. J Am Soc Nephrol 1999; 19(3): 552-61
[21] 21. Wei C, Möller CC, Altintas MM, et al. Modification of kidney barrier function by the urokinase receptor. Nat Med 2008; 14(1): 55-63.
[22] 22. Takehiko W, Nangaku M. A circulating permeability factor in focal segmental glomerulosclerosis: the hunt continues. Clin Kidney J 2015; 8(6): 708-15.
[23] 23. Sinha A, Baggha A. Rituximab therapy in nephrotic syndrome: implications for patients' management. Nat Rev Nephrol 2013, 9: 154-169.
[24] 24. Fornoni A, Sageshima J, Wei C, et al. Rituximab targets podocytes in recurrent focal segmental glomerulosclerosis. Sci Transl Med 2011; 3(85): 85ra46.
[25] 25. Wang CS, Liverman RS, Garro R, et al. Ofatumumab for the treatment of childhood nephrotic syndrome. Pediatr Nephrol 2017; 32(5): 835-841
[26] 26. Takahashi Y, Ikezumi Y, Saitoh A. Rituximab protects podocytes and exerts anti-proteinuric effects in rat adriamycin-induced nephropathy independent of B-lymphocytes. Nephrology (Carlton) 2017; 22(1): 49-57.
[27] 27. Baum MA, Stablein DM, Panzarino VM, et al. Tejani A, Harmon WE, Alexander SR. Loss of living donor renal allograft survival advantage in children with focal segmental glomerulosclerosis. Kidney Int 2001; 59(1):328‐333.
[28] 28. Selewski DT, Troost JP, Massengill SF, et al. The impact of disease duration on quality of life in children with nephrotic syndrome: a Midwest Pediatric Nephrology Consortium study. Pediatr Nephrol 2015; 30(9):1467-76.
[29] 29. Troost JP, Waldo A, Carlozzi NE, et al. The longitudinal relationship between patient-reported outcomes and clinical characteristics among patients with focal segmental glomerulosclerosis in the Nephrotic Syndrome Study Network. Clin Kidney J 2019; 13(4):597-606.
[30] 30. Rüth EM, Landolt MA, Neuhaus TJ, Markus J Kemper. Health-related quality of life and psychosocial adjustment in steroid-sensitive nephrotic syndrome. J Pediatr 2004;145(6):778-83.
[31] 31. Wallace J, Yorgin PD, Carolan R, et al. The use of art therapy to detect depression and post-traumatic stress disorder in pediatric and young adult renal transplant recipients. Pediatr Transplant 2004 Feb; 8(1):52-9.
[32] 32. Wong G, Chua S, Chadban SJ, al. Waiting time between failure of first graft and second kidney transplant and graft and patient survival. Transplantation 2016;100(8):1767-75.
[33] 33. Van Arendonk KJ, Garonzik Wang JM, Deshpande NA, et al. Practice patterns and outcomes in re-transplantation among pediatric kidney transplant recipients. Transplantation 2013;95: 1360-1368).
[34] 34. Foster BJ, Dahhou M, Zhang X, et al. Association between age and graft failure rates in young kidney transplant recipients. Transplantation 2011; 92(11): 1237-43.
[35] 35. Foster BJ, Dahhou M, Zhang X, et al. High risk of graft failure in emerging adult heart transplant recipients. Am J Transplant 2015; 15(12): 3185-93.