Recurrence of FSGS post kidney transplantation: Salvage therapy with ACTHAR® gel.

Introduction:

Recurrence of FSGS post kidney transplantation may reach 25-50%. Failure of treatment or incomplete remission often leads decreased graft survival. Therapeutic plasma exchange (TPE) remains the main stay of therapy for recurrent FSGS. Alternative therapies include steroids, calcineurin inhibitors and rituximab. Resistance to treatment is not uncommon.

Description:

We report 6 patients (4 female and 2 male, 3 deceased and 3 living donor recipients, age 28-58 years), who developed biopsy proven recurrent FSGS at 12.5 months (range 0.1-42) post-transplantation and were resistant to TPE, defined as no response in proteinuria after high dose steroids and TPE 3-5 times a week for at least 3 months post FSGS diagnosis. Two patients had also failed rituximab administration. Maintenance immunosuppression included tacrolimus and MMF.

ACTHAR gel was dosed at 80 units SQ twice (n=5) or thrice (n=1) a week. All patients have received ACTHAR for at least 3 months so far. Response to therapy is defined as being able to discontinue TPE and have a sustained remission with urine P/C ratio < 0.5. Maintenance immunosuppression of prednisone 5 mg qd, tacrolimus and MMF was maintained during ACTHAR therapy.

Results:

At the most recent follow up, 5 patients were off TPE and 1 patient is being tapered, currently at 1 treatment a week. Proteinuria (protein-creatinine ratio) improved in all patients from average baseline values of 3.75 g/g cr, to 2.1 g/g cr at 3 months and 1.3 g/g cr at 6 months (p<0.01 vs baseline). Renal function was maintained during ACHTAR therapy, with average serum creatinine baseline values of 1.9 mg/dL, 1.9 mg/dL at 3 months and 1.8 mg/dL at 6 months. Overall, ACTHAR was well tolerated. Cushingoid features were observed in 2 patients, transient BK viremia (n=1), pneumonia (n=1) and line sepsis (n=1). Average HbA1c during the study period was 6.2, no change from baseline.

Conclusion:

In patients who failed prolonged TPE and high dose steroids after recurrence of FSGS post-transplantation, the addition of ACTHAR gel induced remission of the nephrotic syndrome in all patients, allowing the discontinuation of TPE completely in 5 out of 6 patients; 1 is currently down to only once a week. Our experience shows that ACTHAR is effective in achieving remission for patients who failed conventional therapy. Our results support the need for a controlled trial of ACHTAR gel in recurrent FSGS after kidney transplantion.

CITATION INFORMATION: Vaitla P, Daswatta D, Guasch A. Recurrence of FSGS Post Kidney Transplantation: Salvage Therapy with ACTHAR® Gel. Am J Transplant. 2016;16 (suppl 3).

« Back to 2016 American Transplant Congress