Rituximab and chronic plasmapheresis therapy of nephrotic syndrome in renal transplantation patients with recurrent focal segmental glomerulosclerosis.

Focal segmental golmerulosclerosis (FSGS) recurs in 30% of patients with FSGS who received a first renal transplant and in more than 80% of patients receiving a second transplant after a recurrence. Plasmapheresis (PP) can reduce proteinuria and even induce complete remission of proteinuria. We studied the effects of rituximab therapy associated with chronic PP treatment of nephrotic syndrome among 3 adult renal transplant recipients with recurrent FSGS after a fourth, a second, or a third transplantation, respectively. All of these subjects had displayed recurrences in previous transplants. The 3 patients were treated with PP once a week after recurrence; the first and second patients were treated with PP before transplantation surgery seeking to prevent FSGS recurrence. The patients' follow-up times were 21, 35, and 33 months, respectively, before rituximab therapy. During that time, the patients were treated with 133, 62, and 94 PP sessions, respectively. All of the patients received rituximab (375 mg/m(2)/wk, 4 doses) and 1 PP session before each rituximab dose. We confirmed the effectiveness of rituximab therapy by demonstrating peripheral CD19 cells to be undetectable after therapy. None of the patients treated with rituximab achieved remission of proteinuria. One patient showed proteinuria reduced by 26%, the second by 44%, and the third had no change. None of the patients had infectious complications or graft loss at 1 month follow-up. Our experience with 3 adult renal transplant recipients with recurrent FSGS and chronic PP therapy showed failure of rituximab to achieve remission in nephrotic syndrome.