Rituximab therapy in early recurrent focal segmental sclerosis after renal transplantation.

Kidney transplants may be lost due to recurrence of the primary disease. In glomerulonephritis, all kinds taken together, 3% of the patients lose their grafts due to recurrence [1]. If, however, a first kidney graft has been lost from recurrence, the rate of failure caused by recurrence in subsequent grafts is ∼48% [1]. Focal segmental glomerulosclerosis (FSGS) in a young patient is associated with the highest rate of recurrence in kidney grafts, i.e. 20–40% of first time kidney recipients [1–3]. With recurrence of childhood FSGS, the 2-year graft survival is poor—∼35% [1]. A circulating factor, which may increase the glomerular permeability to albumin, has been found in some patients with FSGS. Therefore, several trials with plasmapheresis or protein A immunoabsorption have been conducted in patients with recurrent FSGS, but the response appears to be variable and unpredictable [2,3]. Rituximab was first given to a few patients with post-transplant lymphoproliferative disorder and early recurrent FSGS. The lymphoproliferative disorders dissolved, and as a side effect, proteinuria improved [4,5]. Subsequently, rituximab therapy has been reported in several kidney transplants with early recurrent FSGS, but has achieved variable results (Table 1) [6–13]. It is difficult to organize randomized trials in this small patient group. Therefore, we report a case of sustained remission after rituximab in a young patient with resistant early remission of FSGS in his second kidney graft.