Re-transplantation in pediatric patients with failure of primary transplant due to recurrent focal segmental glomerulosclerosis: A pediatric nephrology research consortium study

Abstract

Introduction: Recurrent focal and segmental glomerulosclerosis (FSGS) in kidney transplant recipients is associated with lower graft survival and increased morbidity. There are limited data to guide the decision to re-transplant patients with transplant failure due to FSGS recurrence. We aimed to evaluate outcomes in patients re-transplanted after having initial graft failure due to recurrent FSGS and to study physician attitudes and practice patterns.

Methods: Retrospective data from 10 centers were collected on 20 patients transplanted between January 1997 and September 2018. A survey was sent to nephrologist members of the Pediatric Nephrology Research Consortium.

Results: Mean patient age (years) was 9.8 ± 4.8 at first transplant and 15.9 ± 4.9 at re-transplantation. Pre-transplant plasmapheresis was used in 1 (5.3%) primary transplant vs. 7 (38.9%) re-transplants (p = .03). Nephrotic syndrome recurred in 14 patients (70%) after re-transplantation and was severe in 21.1% vs. 64.7% after first transplant (p = .04). Graft survival was significantly higher in the second transplant (p .009) with 70% having functioning grafts at a median of 25.2 months. Thirty-one physicians from 21 centers completed the survey, 94% indicated they would re-transplant such patients, 44.4% preferred a minimum waiting period before re-transplantation, 36.4% preferred living donors, and 22.2% indicated having protocols for re-transplantation at their centers.

Conclusions: Consideration for re-transplantation is high among pediatric nephrologists. Pre-transplant plasmapheresis was more frequent in re-transplanted patients. Nephrotic syndrome recurrence was less severe, with better graft survival. More data and a larger population are necessary to further evaluate outcome determinants and best practices in this special population.

Keywords: FSGS; graft survival; nephrotic syndrome; plasmapheresis; re-transplantation; recurrence of FSGS.

FIGURE 1

Kaplan Meier survival analysis. Graft survival in first and second transplants, Long-rank test p = .009

FIGURE 2

Nephrologist survey responses – factors affecting decision to re-transplant. Numbers reflect priority of response, with the most significant factor assigned the number 1, and least important factor assigned the number 10. Percentages on the horizontal bars reflect the proportion of responses to the specific question

FIGURE 3

Nephrologist survey responses – most effective therapies. Numbers reflect priority of response, with the therapy viewed as most effective assigned the number 1, and the least effective assigned the number 4 (the number 5 was for other – there were no responses). Percentages on the horizontal bars reflect the proportion of responses to the specific question