Journal de néphrologie et thérapeutique

Rituximab (RTX) and Plasmapheresis in a Recurrent Segmental and Focal Glomerulosclerosis (FSGS) Case after Kidney Transplantation

Abstract

Abdellaoui I, Azzabi A, Sahtout W, Benaicha N, Guedri Y, Zallama D and Achour A

A 21-year-old male patient whose primary kidney disease was focal segmental glomerulosclerosis (FSGS) received a living kidney transplant 7 years after starting hemodialysis (haploidentic from his mother). His kidney disease was primary recurrent FSGS treated since the age of four with corticosteroids and switching different options of Immunosuppressive treatment Calcineurin inhibitors and mycophenolate Mofetil). The transplantation induction protocol was Corticosteroid (CS) boli and Basiliximab without added preventive Therapeutic Plasma Exchange (TPE/ Plasmapheresis) sessions. Then for maintain, he took CS, Mycophenolate Mofetil and Cyclosporine A. After 9 liters of urine output at day zero after transplantation, he developed severe recurrence of proteinuria (up to 23 g/24 hat day 2) and anuria with creatinin level ascension to reach 500 micromol/l. The immunosuppressive treatment consisted of ten daily Plasmapheresis sessions, five intravenous doses of Rituximab (RTX-375/m2) 700 mg at days 1, 5, 9, 13 and three boli of CS (500 mg) in addition to Cyclosporine (oral). At hospital discharge (1 month), proteinuria increased below nephrotic range at day 14 and serum creatinine returned progressively to normal values. He underwent two other Plasmapheresis sessions (TPE) but the third was delayed because of technical problems. At the sixth month, urine output decreased and proteinuria rose again. It was a relapse. Histology examination showed recurrence signs and he underwent additional Plasmapheresis sessions, another RTX intravenous dose, 500 mg of CS and switched to Tacrolimus. This strategy allowed obtaining sustained full remission of the proteinuria and excellent graft function, which persists over 9 months after transplantation. No notable adverse events related to RTX or TPE were observed. This case confirms that RTX associated with Plasmapheresis may be an effective treatment of recurrent Nephrotic Syndrom (NS) due to FSGS.