Recurrence of FSGS after Kidney Transplantation in Adults

Clin J Am Soc Nephrol. 2020 Feb 7;15(2):247-256. doi: 10.2215/CJN.08970719. Epub 2020 Jan 23.


Background and objectives: FSGS recurrence after kidney transplantation is a major risk factor for graft loss. However, the natural history, clinical predictors, and response to treatment remain unclear because of small sample sizes and poor generalizability of single-center studies, and disease misclassification in registry-based studies. We therefore aimed to determine the incidence, predictors, and treatment response of recurrent FSGS in a large cohort of kidney transplant recipients.

Design, setting, participants, & measurements: The Post-Transplant Glomerular Disease (TANGO) project is an observational, multicenter, international cohort study that aims to investigate glomerular disease recurrence post-transplantation. Transplant recipients were screened for the diagnosis of idiopathic FSGS between 2005 and 2015 and details were recorded about the transplant, clinical outcomes, treatments, and other risk factors.

Results: Among 11,742 kidney transplant recipients screened for FSGS, 176 had a diagnosis of idiopathic FSGS and were included. FSGS recurred in 57 patients (32%; 95% confidence interval [95% CI], 25% to 39%) and 39% of them lost their graft over a median of 5 (interquartile range, 3.0-8.1) years. Multivariable Cox regression revealed a higher risk for recurrence with older age at native kidney disease onset (hazard ratio [HR], 1.37 per decade; 95% CI, 1.09 to 1.56). Other predictors were white race (HR, 2.14; 95% CI, 1.08 to 4.22), body mass index at transplant (HR, 0.89 per kg/m2; 95% CI, 0.83 to 0.95), and native kidney nephrectomies (HR, 2.76; 95% CI, 1.16 to 6.57). Plasmapheresis and rituximab were the most frequent treatments (81%). Partial or complete remission occurred in 57% of patients and was associated with better graft survival.

Conclusions: Idiopathic FSGS recurs post-transplant in one third of cases and is associated with a five-fold higher risk of graft loss. Response to treatment is associated with significantly better outcomes but is achieved in only half of the cases.

Keywords: Nephrectomy; adult; body mass index; cohort studies; focal segmental glomerulosclerosis; graft survival; humans; incidence; kidney; kidney diseases; kidney transplantation; plasmapheresis; recurrence; registries; renal transplantation; risk factors; rituximab; sample size; transplant outcomes; transplant recipients; treatment outcome.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Brazil
  • Europe
  • Female
  • Glomerulosclerosis, Focal Segmental / diagnosis
  • Glomerulosclerosis, Focal Segmental / physiopathology
  • Glomerulosclerosis, Focal Segmental / surgery*
  • Graft Survival* / drug effects
  • Humans
  • Immunosuppressive Agents / therapeutic use
  • Kidney Transplantation / adverse effects*
  • Male
  • Middle Aged
  • Plasmapheresis
  • Recurrence
  • Retreatment
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Rituximab / therapeutic use
  • Time Factors
  • Treatment Outcome
  • United States


  • Immunosuppressive Agents
  • Rituximab