Introduction: The rapid recurrence of proteinuria in some patients with focal segmental glomerulosclerosis (FSGS) immediately after transplantation suggests possible injury of podocytes by a circulating permeability factor. For this reason, plasma exchange is used to remove the factors from the blood and alleviate the disease, and rituximab influences the formation of the permeability factor but with variable response rates. Data on the efficacy of immunoadsorption in treating FSGS recurrence is scarce.
Method: We describe two patients with FSGS recurrence who failed to respond to rituximab and plasma exchange treatments and underwent immunoadsorption.
Results: A 21-year-old male underwent his second kidney transplantation from a deceased donor in February 2022 after the loss of the first allograft one-month posttransplant due to recurrent FSGS unresponsive to rituximab and plasma exchanges. Despite the rituximab applied in two doses and 14 plasma exchanges, recurrent FSGS after the second transplant resulted in progressive proteinuria reaching 20.9 g/day. In September 2022, he was started with immunoadsorption twice a week. Proteinuria declined to 7.7 g/day after 5 procedures but gradually decreased, finally stabilizing at 0.3-0.6 g/day with 1 IA every 2 weeks with excellent allograft function.
Another patient is a 46-year-old man who experienced a recurrence of FSGS in the early posttransplant period with proteinuria 7.57 g/day despite the rituximab and plasma exchange treatment. He underwent 32 PEs with the lowest proteinuria 3.5 g/day. In April 2023, he was switched to IA. After 8 procedures, his proteinuria decreased to 0.48 g/day. He continued with IAs once a week with stable kidney function after 53 procedures (creatinine clearance 113 mL/min/1.73m2) and proteinuria 0.3 g/day.
Conclusion: In our patients, immunoadsorption was found to be efficient for treating FSGS recurrence in patients who failed to respond to PE and rituximab.