The role of plasma exchange in treating post-transplant focal segmental glomerulosclerosis: A systematic review and meta-analysis of 77 case-reports and case-series.

Abdullah Kashgary,Lihua Li,Jessica M. Sontrop,William F. Clark,Roaa Alsolaimani,Zainab N. Habibullah,Ahmed A. Al-Jaishi

doi:10.1186/s12882-016-0322-7

Abstract

BackgroundEvidence on the role of plasma exchange for treating recurrent post-transplant focal segmental glomerulosclerosis (FSGS) comes largely from individual cases and uncontrolled series. We conducted a systematic review and meta-analysis to estimate the remission rate after treatment with plasma exchange, and to determine if remission varied with patient or treatment characteristics.MethodsWe searched MEDLINE, EMBASE, Science Citation Index Expanded, and the Conference Proceedings Citation Index (Science and BIOSIS) for studies of patients with post-transplant recurrent FSGS who were treated with plasma exchange after recurrence (1950–2012). Of 678 studies screened, 77 met our inclusion criteria: 34 case reports (45 patients) and 43 case series (378 patients). We extracted patient-level data from each study and used random-effects models to calculate remission, defined as proteinuria <3.5 g/day (partial) or <0.5 g/day (complete).ResultsThe overall remission rate in 423 patients with outcome data was 71 % (95 % CI: 66 % to 75 %). In 235 patients with data on age, remission was similar for adults and children: 69.1 % (95 % CI: 59.6 % to 77.2 %) and 70.2 % (95 % CI: 61.1 % to 77.9 %). Males were more likely to achieve remission (OR = 2.85; 95 % CI: 1.44 to 5.62) and patients treated within 2 weeks of recurrence showed a trend towards higher likelihood of remission (OR = 2.16; 95 % CI: 0.93 to 5.01). Proteinuria >7 g/day at recurrence was inversely associated with remission (OR = 0.43; 95 % CI: 0.19 to 0.97). Age and type of kidney transplant (living vs. deceased) did not associate with remission.ConclusionIn this systematic review of patients with recurrent post-transplant FSGS, 71 % of patients achieved full or partial remission after treatment with plasma exchange; however, extensive missing data and lack of a control group limit any conclusions on causality.Electronic supplementary materialThe online version of this article (doi:10.1186/s12882-016-0322-7) contains supplementary material, which is available to authorized users.

Highlights

Evidence on the role of plasma exchange for treating recurrent post-transplant focal segmental glomerulosclerosis (FSGS) comes largely from individual cases and uncontrolled series
Treatment with plasma exchange became a logical step when several subtypes of FSGS were found to recur in allograft-transplanted kidneys, and with the discovery of potential pathological circulating factors [7,8,9,10]
We conducted a systematic review of all relevant studies of patients with posttransplant recurrent FSGS who were treated with plasma exchange after recurrence

Summary

Introduction

Evidence on the role of plasma exchange for treating recurrent post-transplant focal segmental glomerulosclerosis (FSGS) comes largely from individual cases and uncontrolled series. Focal segmental glomerulosclerosis (FSGS) is the most common acquired cause of kidney failure in children (after hereditary causes), and accounts for nearly 40 % of cases of nephrotic syndrome in adults [1, 2]. Treatment with plasma exchange became a logical step when several subtypes of FSGS were found to recur in allograft-transplanted kidneys, and with the discovery of potential pathological circulating factors [7,8,9,10]. While current guidelines support the use of plasma exchange for recurrent post-transplant FSGS, evidence on treatment efficacy comes largely from case reports and uncontrolled case series [3, 13]. We extracted patient-level data from these studies, and estimated the rate of remission after treatment (defined as proteinuria

Methods

Results

Discussion

Conclusion