*Purpose: Up to 30% of patients with focal segmental glomerulosclerosis (FSGS) experience recurrent disease after renal transplant, with high rates of progression to allograft failure (84% at 3 years). Case studies have demonstrated reversibility of the disease following re-transplantation. The aim of this study was to explore outcomes of patients with recurrent FSGS post-transplant at UCLA.

*Methods: A retrospective chart review was conducted. Between 1/2014 and 8/2019, 1860 kidney transplantations were performed, 100 of which were due to biopsy-proven FSGS. Patients were considered to have recurrent disease if they received treatment based on a rising urine protein to creatinine ratio and/or had biopsy-proven recurrence. Descriptive and comparative statistics were obtained, with analysis completed in R 3.6.1.

*Results: Twenty-six recipients experienced FSGS recurrence. Patients with recurrence were younger (34.3 vs. 44.8, p=0.003) and more likely to have a history of native nephrectomy (7 vs. 2, p=0.003). Gender, race/ethnicity, Charlson comorbidity index, BMI, distribution of transplant type (living versus deceased or en bloc transplants) and rates of rejection were similar between the recurrence and non-recurrence groups. Most patients received plasmapheresis (n=23) with or without rituximab for treatment (n=11) which allowed for complete recovery in 18 patients (69%). Because of disease recurrence, 3 patients returned to dialysis (one of whom elected allograft nephrectomy and re-transplantation on post-op day 5) and 5 are chronically pheresis-dependent. Those experiencing a durable recovery required a median of 6 pheresis sessions (range 2-71, see graph).

*Conclusions: Most patients with recurrent FSGS experience complete recovery with early plasmapheresis, usually within 6 pheresis sessions. There may be a point of diminishing return in the management of recurrent FSGS in which additional pheresis fails to prevent graft failure and may open the possibility of re-transplantation to prevent early graft loss.

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