ESPN 50th Annual Meeting

ESPN 2017

Rituximab and plasma exchange does not prevent disease recurrence in high risk FSGS following living donor transplantation
Mohan Shenoy 1 Amrit Kaur 1 Rachel Lennon 1 Nicholas Webb 1 Nicholas Plant 1

1- Royal Manchester Children’s Hospital

For patients with end stage renal failure (ESRF) secondary to focal segmental glomerulosclerosis (FSGS), disease recurrence (DR) following renal transplantation (RT) is a significant concern. Patients with rapidly progressive primary disease, negative genetic screening and those with previous graft loss secondary to DR are most at risk. There is no consensus regarding the prevention and management of DR.

Material and methods:

Four children with high risk FSGS, including 2 with previous graft loss due to DR, underwent living donor RT. All were managed with a uniform protocol of a single dose of rituximab (375mg/m2) 4 weeks prior to RT and 4 sessions of plasma exchange (PE) over the week prior to RT. DR was defined as urine protein:creatinine ratio >200mg/mmol on 2 consecutive days.


One child with previous graft loss (Pt 1) had immediate DR and received PE for 5 months post-transplant. Another had immediate DR as well as impaired graft function and following a partial response to PE, developed graft failure at 6 months. The third, who had previous graft loss (Pt 3) had DR at day 4 which responded to 5 sessions of PE. The fourth child had a comparatively late DR at 1 month and has continued on weekly PE 7 months.

Pt no 1 2 3 4
Sex M F F M
Immunosuppression Ba/T/MMF Ba/T/MMF Ba/T/MMF/P Ba/T/MMF
Age at Tx 16 14 12 6
Previous Tx Y N Y N
Time to recurrence 3 days 3 days 4 days 30 days
No of PE sessions 31 52 5 20
Duration of FU 24mo 11mo 8mo 7mo
Last urine PCR 164 585 22 43
Current eGFR 54 <15 138 90





In this small cohort of patients with high risk FSGS, rituximab and PE pre-RT, did not reduce the risk of DR. However, in children with DR, including 2 patients with previous graft loss, the disease responded well to PE. We are encouraged by our data to continue advocating the use of living donors for this difficult group of patients.