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P5.27 Treatment of Post-Transplant Recurrent FSGS in Children Using Plasmapheresis and Augmentation of Immunosuppression

Jaime Restrepo, Colombia

Professor and chief of Pediatric nephrology service
Mother and child division
Hospital Universitario Fundación Valle del Lili


Treatment of Post-Transplant Recurrent FSGS in Children Using Plasmapheresis and Augmentation of Immunosuppression

Jaime Restrepo1,3,5, Laura A. Torres-Canchala2, Vanessa Ochoa1, Hernando Londoño1, Michael J.G. Somers4, Eliana Manzi5.

1Pediatric Nephrology service, Fundación Valle del Lili, Cali, Colombia; 2Clinical research center, Fundación Valle del Lili, Cali, Colombia; 3Health science department, Universidad Icesi, Cali, Colombia; 4Division of Nephrology, Boston Children’s Hospital, Boston, MA, United States; 5Sister Renal Center Program, International Society of Nephrology, Boston, MA, United States

Background: Up to 60% of pediatric renal transplant recipients with end-stage renal disease due to primary focal and segmental glomerulosclerosis (FSGS) may develop recurrent disease. Such recurrence is associated with poor prognosis if no remission is achieved. We report a single center experience with a protocol based on plasmaphereis and increased immunosuppression that resulted in a high long-lived remission rates.
Methods: This retrospective cohort study included consecutive pediatric renal transplant patients with recurrent FSGS treated with a standardized protocol using plasmapheresis and cyclophosphamide to supplement usual post-transplant immunosuppression with calcineurin inhibitors and steroids. Relapse was defined as urinary protein/creatinine ratio >1.0g/g and remission as <0.5g/g.
Results: 17 patients with FSGS recurrence post-transplant were treated. All had therapy-resistant FSGS in native kidneys and had been on dialysis from 4-10 years. Of the 17, one died perioperatively from a pulmonary thromboembolism. 12 others achieved a complete remission within 3 months of treatment for FSGS recurrence. After a median follow-up period of 4 years, there were no recurrences of significant proteinuria.  
Conclusion: The addition of plasmapheresis and cyclophosphamide to a calcineurin- and steroid-based immunosuppression regime could be an successful in inducing high remission rates with recurrent FSGS.  Prospective trials are needed to evaluate further the efficacy of increased immunosuppression along with plasmapheresis  in this setting.
Keywords: Focal and segmental glomerulosclerosis, renal transplantation, recurrence, plasmapheresis, cyclosphosphamide, pediatric