Outcomes of recurrent focal segmental glomerulosclerosis post kidney transplantation

Abstract

Introduction: Recurrent focal segmental glomerulosclerosis (FSGS) after kidney transplantation contributes to poor graft outcomes[1]. There is uncertainty around using living donors for patients with FSGS because of concerns of an increased risk of disease recurrence in the transplanted kidney resulting in poorer transplant outcomes[2]. We aimed to determine the effect of donor source on recurrence and graft survival in patients with FSGS. Materials and Methods: Using the Australian and New Zealand Dialysis and Transplant registry, we compared the risk of FSGS recurrence and graft loss between living donor (LD) and deceased donor (DD) kidney transplants in children and adults with biopsy proven FSGS over a twenty-year period. Statistical analysis included paired t test, chi squared and logistic regression analysis. Results: Between 1992 and 2011, 736 first kidney transplants were performed in 666 adults and 70 children with primary FSGS. FSGS recurred in 76 (10.3%) patients and was more common in recipients of a LD transplant compared with DD (14% vs 8%, respectively, p=0.03). However, graft failure due to recurrent disease in the first 5 years after transplant (30 patients, 39%) was more common in DD recipients compared with LD recipients (20 vs 10, p=0.011) and median graft survival was significantly better for LD compared to DD grafts (14.8 years vs. 12.1 years; P=0.005). On logistic regression, younger age and non-caucasian ethnicity were the only independent factors associated with increased risk of recurrence. Disease recurrence predicted poor graft outcomes with 51% (95% CI 38-62%) 5 year graft survival in the recurrence group compared to 83% (95% CI 79-86%) 5 year graft survival in the group without recurrent disease (p= <0.0001). In those with disease recurrence, the majority of graft loss occurred in the first two years. Discussion: Our study confirms that recurrent FSGS after kidney transplant predicts poor graft outcomes. Whilst FSGS more commonly recurred in LD grafts, graft survival in LD recipients was significantly better for both children and adults with FSGS. We postulate that the well described graft survival advantage of LD grafts may overcome the negative effect of increased risk of recurrence, with its attendant poor prognosis. Short term studies of outcomes of kidney transplantation for FSGS would only capture the adverse effects of early recurrence and graft loss, but long term follow up reveals the improved outcomes for LD grafts. Conclusion: We propose live donor transplantation should not be avoided in patients with FSGS.L6130046002016-11-08 <br />