Therapeutic Approach to Focal and Segmental Glomerulosclerosis (FSGS) Recurrence in Kidney Transplant Recipients

Primary focal and segmental glomerulosclerosis (FSGS) is the most frequently acquired disease leading to end stage renal disease (ESRD) in children (NAPRTCS 2004, annual report)1-6. The recurrence of FSGS after kidney transplantation is frequent (20-40%) and is associated with poor graft survival7-13. The pathophysiology of primary FSGS remains uncertain, but secretion of a circulating factor is suspected to play a key role in excessive glomerular permeability. Excepted for the recurrence of FSGS with a previous allograft, this event is almost unpredictable and characterized by early nephrotic range proteinuria. Some studies have identified risk factors for recurrent FSGS in children, including rapid progression to ESRD, young age of onset of FSGS and, of course loss of a previous graft from recurrent disease but none of these studies can clearly separate the patients who will or will not be affected by recurrence. The treatment of recurrence remains controversial, and most reports relate to use of plasma exchange (PE) in uncontrolled trials with relatively small groups of patients and conflicting results. PE and protein immunoadsorption can markedly reduce urinary protein excretion and induce complete remission in some cases, but they usually fail to achieve sustained remission14-16. Steroids and cyclosporine are also associated with inconstant remission and act through different ways. More recent therapeutic approach seems promising and need to be evaluated in large trials. This review summarizes the various therapeutic approaches to FSGS recurrence.