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ACTH Gel in Resistant Focal Segmental Glomerulosclerosis After Kidney Transplantation

Alhamad, Tarek, MD1,2; Manllo Dieck, John, MD3; Younus, Usman, MD1; Matar, Dany, MD4; Alasfar, Sami, MD4; Vujjini, Vikas, MD5; Wall, Devin, MS1; Kanawati, Bilal, MD1; Reiser, Jochen, MD, PhD6; Brennan, Daniel C., MD4; Alachkar, Nada, MD4

doi: 10.1097/TP.0000000000002320
Original Clinical Science—General
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Background Treatment of focal segmental glomerular sclerosis (FSGS) after kidney transplantation is challenging with unpredictable outcomes. The objective was to investigate the use of adrenocorticotropic hormone (ACTH) analogue gel in kidney transplant recipients with de novo or recurrent FSGS resistant to therapeutic plasma exchange (TPE) and/or rituximab.

Methods We performed a retrospective review of cases of de novo or recurrent resistant FSGS at 2 large US transplant centers between April 2012 and December 2016. Proteinuria was measured by urine protein to creatinine ratio.

Results We identified 20 cases of posttransplant recurrent and de novo FSGS resistant to conventional therapy with TPE and rituximab. Mean ± SD age was 49 ± 15.5 years, 14 (70%) were male, 13 (65%) were whites, and 8 (38%) had previous kidney transplants. Median (interquartile range) of recurrent and de novo FSGS was 3 (0.75-7.5) months posttransplant. The majority of patients, 15 (75%), received TPE as a treatment at the time of diagnosis and 10 (50%) received rituximab, which was started before the use of ACTH gel. There was a significant improvement of urine protein to creatinine ratio from a mean ± SD of 8.6 ± 7.6 g/g before ACTH gel to 3.3 ± 2.3 g/g after the use of ACTH gel (P = 0.004). Ten (50%) patients achieved complete or partial remission.

Conclusions Although, the response varied among the recipients, ACTH gel might be an effective therapy for posttransplant resistant FSGS cases that fail to respond to TPE and rituximab.

1 Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO.

2 Transplant Epidemiology Research Collaboration (TERC), Institute of Public Health, Washington University School of Medicine, St. Louis, MO.

3 South Texas Kidney Specialists, McAllen, TX.

4 Division of Nephrology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD.

5 Department of Medicine, Sinai Hospital, Baltimore, MD.

6 Department of Medicine, Rush University, Chicago, IL.

Received 17 October 2017. Revision received 1 May 2018.

Accepted 7 May 2018.

T.A. has a research grant from Mallinckrodt. J.R. is a cofounder and stockholder of Trisaq; a biotechnological company developing novel therapeutics for chronic kidney diseases and FSGS, and has pending and issued patents in the therapeutic and diagnostic space regarding kidney diseases. The rest of the authors declare no conflict of interest.

A research grant was received from Mallinckrodt, Tarek Alhamad.

ORCID number: 0000-0003-4289-0817 (T.A.).

T.A. participated in design of the work, data collection, data analysis and interpretation, drafting the article, final approval of the version to be published. J.M.D. participated in data collection and analysis. U.Y. participated in data collection. D.M. participated in data collection. S.A. participated in data collection. V.V. participated in data collection. D.W. participated in data collection. B.K. participated in data collection. J.R. participated in critical revision of the article. D.B. participated in critical revision of the article. N.A. participated in design of the work, data collection, data analysis and interpretation, drafting the article, final approval of the version to be published.

Correspondence: Nada Alachkar, MD, Division of Nephrology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 Wolfe St., Brady 502, Baltimore, MD 21287. (nalachk1@jhmi.edu).

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