ESPN 51th Annual Meeting

ESPN 2018


 
PLASMAPHERESIS (PE) WITH RITUXIMAB DOES NOT PREVENT FSGS DISEASE RECURRENCE (DR) FOLLOWING LIVING DONOR KIDNEY TRANSPLANTATION (KT)
ADITI SINHA 1 AMRIT KAUR 2 DEAN WALLACE 2 NICHOLAS PLANT 2 RACHEL LENNON 2 NICHOLAS WEBB 2 MOHAN SHENOY 2

1- ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI, INDIA
2- ROYAL MANCHESTER CHILDREN HOSPITAL, MANCHESTER, UK
 
Introduction:

DR following KT is reported to occur in up to 70% of patients with non-genetic FSGS. PE and rituximab have been reported in small case studies to prevent DR.

Material and methods:

We prospectively administered a single dose of rituximab  375 mg/m2  2-4 weeks  prior to  living related donor (LRD) KT followed by 4 sessions of PE in the week leading to  KT, in 4 consecutive patients with ESKD secondary to FSGS (2 boys; Table 1). All patients had undergone native nephrectomies and did not have inherited defects associated with FSGS (next-generation sequencing, Bristol gene panel). Two patients had previous graft loss due to DR. Immunosuppression was as per the TWIST protocol apart from one patient where long-term steroids were continued because of HLAi KT. 

Results:

 Table 1. Patient characteristics.

Patient 1 2 3 4
Age at KT, yr 18 5 13 14
Previous graft loss Yes No Yes No
Days to DR 2 30 2 3
Follow up, months 45 18 19 22
Latest urine protein to creatinine ratio, mg/mmol 381 83 12 144
Latest serum albumin, g/L 29 31 43 37
Latest estimated GFR, ml/min/1.73 m2 55 61 113 11

All 4 patients showed DR 2-30 days after KT, with concomitant acute tubular necrosis and allograft dysfunction in two. Urine protein:creatinine ratio was 329-719 mg/mmol prior to institution of PE. After 4-5 daily followed by alternate day PE 2 patients achieved complete remission (CR) and 1 achieved partial remission (PR). There was no response in 1 patient who progressed to ESKD 5 months following KT despite over 50 sessions of PE. At last follow-up 18 – 45 months following LRD, 2 patients remain in CR while one has persistent proteinuria, with good graft function.

Conclusions:

 The combination of rituximab and plasmapheresis does not prevent DR following LRD KT in patients with non-genetic form of FSGS. Majority of patients with DR respond to early intensive PE.