*Purpose: FSGS is a leading cause of end stage renal disease (ESRD). Tx in patients with FSGS may lead to graft failure due to recurrence of nephrotic syndrome after Tx. The decision to re-Tx or not, timing, choice of donor, and treatment options have not been standardized. We report outcomes in pediatric kidney Tx recipients with re-Tx after graft failure due to recurrent FSGS.

*Methods: We retrospectively reviewed charts of Tx recipients < 21 years of age who were re-Tx after failure of first Tx from recurrent FSGS. All Tx occurred between 1998 and 2017. Additionally, a questionnaire regarding re-Tx after FSGS recurrence practice patterns was e-mailed to PNRC pediatric nephrologists. Descriptive statistical analyses, Paired tests and Cox Regression adjusting for age were used to compare graft survival.

*Results: There were 14 patients enrolled by 6 centers. The mean age at diagnosis of FSGS was 5.8±4.7 years with ESRD at 9.5±4.2 years, first Tx at 10.2±4.9 years, and second Tx at 16.2±5.5 years. There were no significant differences in donor type, immunosuppression, pheresis, rituximab use, or acute rejection rates (Table 1). FSGS recurred in 11 patients (79%) after second Tx . Mean time to recurrence after first Tx was 26.8 (0.03-211) months vs 6.03 (0.03-24) after second Tx, p=0.03). Severe recurrences were less frequent in re-Tx, 27.3% vs 63.4% after first Tx (p=0.058). 4 of 14 (28.6%) of re-Tx had graft failure (HR 2.17, 95%CI 0.37- 14, p = 0.42) with a mean follow-up of 62.3 (37.8-86.8) months. Median time to graft failure after first Tx was 13.5 months (IQR 4-53) and second Tx was 11 months (IQR 1.5-33.8). 31 pediatric nephrologists from 21 Tx centers responded to the questionnaire. 93.5% of physicians would re-Tx patients with graft failure due to FSGS recurrence, and 44.4% prefer to wait before re-Tx (minimum of 6 months-25%, 1 year-66.7%, and 1-2 years-8.3%). 36.4% of physicians prefer a living donor. 22.2% of centers have a written protocol for re-Tx after FSGS recurrence. 92.6% of physicians decide on re-Tx on an individual basis.

*Conclusions: In this small cohort, FSGS recurrence rate after second Tx was high (79%), with earlier time to recurrence, but less severe recurrence, and graft failure in 28.6%. Factors affecting outcome could not be identified. Although consideration for re-Tx is high among pediatric nephrologists, there is great variation in waiting times before re-Tx, and pre/post-Tx management overall. There is a great need for more data based on a larger population to be able to further study outcome determinants.

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