Impact of Therapeutic Plasma Exchange and Rituximab for Prevention of Idiopathic Focal Segmental Glomerulosclerosis Recurrence Post-Kidney Transplantation

Background. Focal segmental glomerulosclerosis (FSGS) recurs after kidney transplantation (KT) in 30%-50% of recipients. Recurrence is associated with early graft loss in up to 60% of cases. This study aimed to assess the efficacy of therapeutic plasma exchange (TPE) combined with rituximab (RTX) in preventing early FSGS recurrence within 1 y post-KT. Methods. This single-center, retrospective cohort study included patients receiving KT for idiopathic FSGS between June 2013 and August 2021. In May 2016, a preventative FSGS protocol was implemented where KT recipients with idiopathic FSGS received perioperative sessions of TPE followed by a dose of RTX with or without IVIG. The incidence of recurrent FSGS within the first year posttransplantation was assessed between the FSGS protocol cohort versus the historical group of patients who did not undergo prophylactic treatment. Results. A total of 65 patients received KT for idiopathic FSGS during the study period. Forty patients were included in the FSGS protocol cohort and 25 in the control cohort. When assessing clinical recurrence with proteinuria, there were significantly fewer cases in the FSGS protocol cohort versus the control cohort, 1 versus 5 patients (3% versus 20%, P=0.03). There were no instances of death-censored graft loss at 1 y in the protocol cohort versus 2 cases in the control cohort (0% versus 8%, P=0.14). Conclusions. TPE combined with RTX may prevent early FSGS recurrence without significant rates of infection.