A Tale of Five Kidneys and One Heart Transplants

Abstract

Background: Idiopathic focal segmental glomerulosclerosis (FSGS) recurrence occurs in 20-30% of first renal transplant recipients and >80% after a re-transplant after a previous recurrence. Relapse often means graft failure. Case report: A 40-yr-old white female with primary, idiopathic FSGS diagnosed at the age of five years underwent a paired living donor kidney transplantation (her husband having blood group incompatibility). She had already received 4 previous kidney transplants at the age of 9 (mother's kidney), 11, 18 and 32 (cadaver kidneys) years old, the last one simultaneously with a heart transplant. Nephrotic syndrome was immediately diagnosed after the first, third and fourth transplantation, with consequent graft failure secondary to FSGS recurrence (histologically documented) at 6 months, 10 years and 7 years, respectively. The second transplant was lost 24-hour after surgery due to unclear reasons. Considering her past medical history, and the presence of a donor-specific antibody (DSA) (anti-DQ7, MFI 10,500) against the swapped donor (positive B-cell flow cytometry crossmatch, negative CDC crossmatch), we implemented a desensitization/preventive protocol including: plasmapheresis at day -7, -5, -4, -3 and -1 before the transplant; rituximab (375 mg/m2) at days -3, +4, +17; IVIg 1 g/kg at day -1, +1, +2, +3, +4 and +16; and occlusion of native renal arteries. Basiliximab was used for induction, and maintenance immunosuppression consisted of cyclosporine (doses adjusted to maintain C2 levels between 700-800 ng/ml), mycophenolate mofetil (2 g/die) and prednisone (5 mg/day). Serum creatinine was 0.4 mg/dl on day +3. The hightest value of proteinuria was 1.283 g/24h on day 3; the next values reduced progressively and proteinuria was 0.224 g/24h at discharge. The patient was discharged on p.o.d. 18. After 7 months of follow-up, the patient has normal renal function (creatinine level of 0.7 mg/dl), no proteinuria, and a very low titer anti-DQ7 antibody (MFI 1,800). Conclusion: This case reflects the possibility to perform a succesful fifth renal transplant in a patient with FSGS and DSA with a new immunosuppressive and surgical approach.