A Comprehensive Look at Focal Segmental Glomerulosclerosis Recurrence in Adult Transplant Patients: Findings from a Single Institution with Review of Literature

Background: Focal segmental glomerulosclerosis (FSGS) is a kidney disease with diverse causes, classified as primary, genetic, or secondary. There is a high recurrence rate of FSGS posttransplant and is associated with a significant risk of graft loss, especially in the primary cases. In this descriptive study, we aimed to analyze the presentation, treatment response, and outcomes of posttransplant recurrent FSGS (rFSGS) in the Indian population. Methodology: In this retrospective study, from a North Indian tertiary care center, we identified 18 cases of posttransplant rFSGS over 12 years. Therapeutic plasma exchange (TPE) was used in most cases, with rituximab (RTX) added for refractory cases. We collected the pretransplant and posttransplant clinical profiles, treatment, and follow-up of these patients including graft and patient survival, hospitalizations, and infectious disease episodes. Results: We identified 18 cases of posttransplant FSGS recurrence over 12 years, predominantly affecting male recipients who had received live-related renal transplants. Overall, 55.6% of recurrences responded to therapy, with varying degrees of remission achieved. The response rate was better in patients with TPE, especially with RTX. At 10-year follow-up, the patient survival at 10 years was 77.7%. Death-censored graft survival at 10 years was 50% with better graft survival in patients receiving additional RTX. Major infection rates were higher in patients who received TPE with RTX. Conclusion: This study highlights the significant challenge of managing rFSGS posttransplant in an Indian population, with TPE and RTX showing varied success in inducing remission. These findings underscore the importance of tailored therapeutic strategies to improve long-term outcomes in managing rFSGS but emphasize the need for larger randomized trials to confirm these findings.