Audrey Uffing1,2, Maria José Pérez-Sáez1,3, Marilda Mazzali4, Roberto C Manfro5, Andrea Carla Bauer5, Frederico de Sottomaior Drumond5, Michelle M O'Shaughnessy6, Xingxing S Cheng6, Kuo-Kai Chin6, Carlucci G Ventura7, Fabiana Agena7, Elias David-Neto7, Juliana B Mansur8, Gianna Mastroianni Kirsztajn8, Helio Tedesco-Silva8, Gilberto M V Neto8, Carlos Arias-Cabrales3, Anna Buxeda3, Mathilde Bugnazet9, Thomas Jouve9, Paolo Malvezzi9, Enver Akalin10, Omar Alani10, Nikhil Agrawal11, Gaetano La Manna12, Giorgia Comai12, Claudia Bini12, Saif A Muhsin13, Miguel Carlos Riella14, Silvia R Hokazono14, Samira S Farouk15, Meredith Haverly15, Suraj Sarvode Mothi1, Stefan P Berger2, Paolo Cravedi15, Leonardo V Riella16. 1. Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. 2. Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 3. Servicio de Nefrología, Hospital del Mar, Barcelona, Spain. 4. Division of Nephrology, School of Medical Sciences, University of Campinas (UNICAMP), Sao Paulo, Brazil. 5. Division of Nephrology, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil. 6. Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California. 7. Kidney Transplant Service, Hospital das Clinicas-University of Sao Paulo School of Medicine, Sao Paulo, Brazil. 8. Division of Nephrology, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil. 9. Service de Néphrologie Dialyse, Aphérèses et Transplantation, Grenoble University Hospital, Grenoble, France. 10. Montefiore Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. 11. Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. 12. Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Bologna, Italy. 13. Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. 14. Pro-Renal Foundation, Curitiba, Paraná, Brazil; and. 15. Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York. 16. Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; lriella@bwh.harvard.edu.
Abstract
BACKGROUND AND OBJECTIVES: FSGS recurrence after kidney transplantation is a major risk factor for graft loss. However, the natural history, clinical predictors, and response to treatment remain unclear because of small sample sizes and poor generalizability of single-center studies, and disease misclassification in registry-based studies. We therefore aimed to determine the incidence, predictors, and treatment response of recurrent FSGS in a large cohort of kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The Post-Transplant Glomerular Disease (TANGO) project is an observational, multicenter, international cohort study that aims to investigate glomerular disease recurrence post-transplantation. Transplant recipients were screened for the diagnosis of idiopathic FSGS between 2005 and 2015 and details were recorded about the transplant, clinical outcomes, treatments, and other risk factors. RESULTS: Among 11,742 kidney transplant recipients screened for FSGS, 176 had a diagnosis of idiopathic FSGS and were included. FSGS recurred in 57 patients (32%; 95% confidence interval [95% CI], 25% to 39%) and 39% of them lost their graft over a median of 5 (interquartile range, 3.0-8.1) years. Multivariable Cox regression revealed a higher risk for recurrence with older age at native kidney disease onset (hazard ratio [HR], 1.37 per decade; 95% CI, 1.09 to 1.56). Other predictors were white race (HR, 2.14; 95% CI, 1.08 to 4.22), body mass index at transplant (HR, 0.89 per kg/m2; 95% CI, 0.83 to 0.95), and native kidney nephrectomies (HR, 2.76; 95% CI, 1.16 to 6.57). Plasmapheresis and rituximab were the most frequent treatments (81%). Partial or complete remission occurred in 57% of patients and was associated with better graft survival. CONCLUSIONS: Idiopathic FSGS recurs post-transplant in one third of cases and is associated with a five-fold higher risk of graft loss. Response to treatment is associated with significantly better outcomes but is achieved in only half of the cases.
BACKGROUND AND OBJECTIVES:FSGS recurrence after kidney transplantation is a major risk factor for graft loss. However, the natural history, clinical predictors, and response to treatment remain unclear because of small sample sizes and poor generalizability of single-center studies, and disease misclassification in registry-based studies. We therefore aimed to determine the incidence, predictors, and treatment response of recurrent FSGS in a large cohort of kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The Post-Transplant Glomerular Disease (TANGO) project is an observational, multicenter, international cohort study that aims to investigate glomerular disease recurrence post-transplantation. Transplant recipients were screened for the diagnosis of idiopathic FSGS between 2005 and 2015 and details were recorded about the transplant, clinical outcomes, treatments, and other risk factors. RESULTS: Among 11,742 kidney transplant recipients screened for FSGS, 176 had a diagnosis of idiopathic FSGS and were included. FSGS recurred in 57 patients (32%; 95% confidence interval [95% CI], 25% to 39%) and 39% of them lost their graft over a median of 5 (interquartile range, 3.0-8.1) years. Multivariable Cox regression revealed a higher risk for recurrence with older age at native kidney disease onset (hazard ratio [HR], 1.37 per decade; 95% CI, 1.09 to 1.56). Other predictors were white race (HR, 2.14; 95% CI, 1.08 to 4.22), body mass index at transplant (HR, 0.89 per kg/m2; 95% CI, 0.83 to 0.95), and native kidney nephrectomies (HR, 2.76; 95% CI, 1.16 to 6.57). Plasmapheresis and rituximab were the most frequent treatments (81%). Partial or complete remission occurred in 57% of patients and was associated with better graft survival. CONCLUSIONS:Idiopathic FSGS recurs post-transplant in one third of cases and is associated with a five-fold higher risk of graft loss. Response to treatment is associated with significantly better outcomes but is achieved in only half of the cases.
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