title: Recurrent focal glomerulosclerosis in pediatric renal allografts: the Miami experience.
abstract: Recurrence of focal glomerulosclerosis (FSGS) following renal transplantation is a common cause of allograft loss and clinical morbidity. Recent attempts to control proteinuria and morbidity with plasmapheresis (PP) have met with limited success. Our experience with the use of mycophenolate mofetil (MMF) and angiotensin blockade (AB) in the management of refractory FSGS pre transplant suggested its potential benefit in post-transplant recurrence. This report presents our 25-year experience in pediatric renal transplantation of patients with FSGS divided into two treatment eras: Era 1-prior to use of daclizumab (anti-IL-2R) and Era 2-after daclizumab. A total of 179 pediatric patients were transplanted during the 25-year period. FSGS was confirmed in 27 (15%); 16 of 28 allografts (57%) had recurrence of FSGS during the post-transplant period. In Era 1, only 6 of 16 (38%) recurred in the allograft, while 10 of 12 (83%) recurred during Era 2. The odds ratio of recurrence of FSGS in the allograft after induction with anti-IL-2R was 8.3 (95% confidence interval=1.3-52, P =0.02). Only 2 patients in Era 1 received PP, while 10 in Era 2 were entered into an intensive PP protocol followed by maintenance with AB consisting of angiotensin receptor blockers alone, or in combination with angiotensin-converting enzyme inhibitor. Although proteinuria decreased an average of 80+/-16% with PP, the response was variable and severe morbid edema persisted in poor responders. Maximum benefit occurred with the addition of AB and MMF. After a follow-up of 27+/-15 months, proteinuria has shown a sustained decrease of 94+/-8% below baseline. In conclusion, our experience suggests that, with recurrent FSGS, a limited course of PP followed by maintenance therapy with AB and MMF improves symptoms and may preserve allograft function.
authors.affiliation: Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960 (M-714), Miami, FL 33101, USA.
authors.forename: Hans
authors.initials: H
authors.lastname: Hubsch
authors.forename: Brenda
authors.initials: B
authors.lastname: Montané
authors.forename: Carolyn
authors.initials: C
authors.lastname: Abitbol
authors.forename: Jayanthi
authors.initials: J
authors.lastname: Chandar
authors.forename: Sherry
authors.initials: S
authors.lastname: Shariatmadar
authors.forename: Gaetano
authors.initials: G
authors.lastname: Ciancio
authors.forename: George
authors.initials: G
authors.lastname: Burke
authors.forename: Joshua
authors.initials: J
authors.lastname: Miller
authors.forename: José
authors.initials: J
authors.lastname: Strauss
authors.forename: Gastón
authors.initials: G
authors.lastname: Zilleruelo
mesh_terms: D000293:Adolescent; D047228:Angiotensin II Type 1 Receptor Blockers / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized; D002648:Child; D002675:Child, Preschool; D000077561:Daclizumab; D005260:Female; D005431:Florida; D005923:Glomerulosclerosis, Focal Segmental / Q000209:etiology / Q000601:surgery* / Q000628:therapy*; D006085:Graft Survival / Q000187:drug effects; D006801:Humans; D007074:Immunoglobulin G / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007223:Infant; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D009173:Mycophenolic Acid / Q000031:analogs & derivatives* / Q000627:therapeutic use; D010956:Plasmapheresis; D012008:Recurrence; D016896:Treatment Outcome
chemical_list: D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; D000077561:Daclizumab; D009173:Mycophenolic Acid