FSGS Are More Likely to Recur After Living Donor Kidney Transplant
FSGS are more likely to recur after living donor kidney transplant.
Focal Segmental Glomerular Sclerosis (FSGS) is a common cause of steroid-resistant Nephrotic Syndrome, and approximately 50% to 70% of patients will eventually progress to end-stage renal disease (ESRD) requiring a kidney transplant. However, the recurrence rate of FSGS after kidney transplantation is higher, affecting 15%~40% of pediatric transplant patients and 4%~66% of adult transplant patients.
Risk factors for recurrence of FSGS were known to include ethnicity, initial steroid therapy response, and donor age > 40 years. Factors that do not affect recurrence of FSGS included HLA mismatch, histological subtype, dialysis timing, and type of immunosuppressant. Hereditary FSGS are less likely to relapse. For a long time, there has been a controversy about the source of kidney for patients with primary FSGS.
Dr. Anna Francis and her colleagues from the Department of Nephrology, Mrs. Chillento's Children's Hospital, South Brisbane, Australia, used the Australian and New Zealand Dialysis and Transplantation Registration System (ANZDATA) to assess the incidence of FSGS and the recurrence rate of FSGS after transplantation. Kaplan-Meier analysis and logistic regression analysis were used to determine the impact of donor kidney types on the recurrence of FSGS after transplantation, and the effect of graft survival rate. The article was published in the Journal CJASN in November 2016.
The researchers collected information about donors (age, race, HLA type, source of donor kidney: living body/cadaver), recipients (age, race, HLA type, diagnosis, dialysis time, transplantation time and whether kidney transplantation is preferred) and outcome of graft (including the recurrence of primary disease confirmed by renal biopsy and graft failure) between January 1992 and December 2011. Because the ANZDATA registration system did not record the results of gene testing, the study could not completely exclude patients with hereditary FSGS.
Finally, 736 first-time kidney transplants were performed in 666 adults and 70 children (defined as less than 20 years old) with primary FSGS confirmed by renal biopsy, and these patients were included in the study.
Recurrence of FSGS (10.3%) occurred in 76 of the 736 patients, which was more common in living donor recipients than in cadaver recipients. Recurrence is most common in the first 2 years after transplantation in both adult and child patients. The recurrence rate of pediatric patients was significantly higher than that of adult patients.
Logistic regression analysis showed that younger age, non-white race and living donors were independent risk factors for FSGS recurrence. There was no significant correlation between HLA mismatch and sex and recurrence. Renal transplantation after 1998 was associated with a lower risk of recurrence.
The 5-year graft survival rate of FSGS recipients was significantly lower than that of non-FSGS recipients. This is particularly significant in children with FSGS.
For FSGS patients, donor origin was significantly associated with graft survival. The median survival time of living donor kidney transplantation was significantly longer than that of cadaveric donor kidney. The 5-year survival rate of living donors was 85%, while that of cadaveric donors was only 76%. The results of children with FSGS were consistent with those of the general population. The 5-year survival rate of living kidney donors was 80% in children, while that of cadaveric kidney donors was only 46%.
Recurrence of FSGS after transplantation is a strong predictor of graft outcomes. The 5-year survival rates of the relapsed group and the non-relapsed group were 52% and 83%, respectively. Most of the graft failures occur in the first two years of disease recurrence, mainly in recipients from cadaveric kidney donors.
This study confirms that recurrence of FSGS is more common after living donor kidney transplantation. Nevertheless, the survival rate of living donor grafts is significantly higher in both adults and children than in cadaver donors, but we recommend that the use of living donor kidneys should be avoided in patients with FSGS.
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