Resolution of Recurrent Focal Segmental Glomerulosclerosis Proteinuria after Rituximab Treatment

Abstract

correspondence n engl j med 354;18 www.nejm.org may 4, 2006 1961 fears. As Dr. Lear states, many beneficiaries (and their providers) are worried, frustrated, and scared. We hope that our guarded optimism will one day seem more prescient than do such fears. At the moment, it appears that patients, doctors, and pharmacists are struggling with information over-load and a panoply of poorly understood options. to the editor: Focal segmental glomeruloscle-rosis recurs in about 30 percent of patients who undergo kidney transplantation for this condition and leads to the nephrotic syndrome and acceler-ated graft loss. 1 Cyclosporine, cyclophosphamide, plasmapheresis, protein A immunoabsorption, and mycophenolate mofetil have been variably effective. 1,2 We report the case of a seven-year-old boy who presented with immediate recurrence of focal segmental glomerulosclerosis after transplantation that subsequently resolved only after rituximab treatment of a transplantation-related lymphoma that occurred five months after the surgery. This child originally had biopsy-proven primary focal segmental glomerulosclerosis with the nephrotic syndrome. After 4.5 years, he progressed to renal failure with a need for dialysis despite therapy with prednisone, cyclophosphamide, and myco-phenolate mofetil. Then, 1.25 years after starting dialysis (the patient had anuria), he received a kid-ney transplant from a deceased adult donor with no HLA-AB matches and one HLA-DR match. His immunosuppressive therapy consisted of tacroli-mus, mycophenolate mofetil, corticosteroids at a tapered dose (with discontinuation after seven days), and daclizumab. Although the initial renal function of the pa-tient was excellent, by two weeks after transplan-tation, the creatinine level had increased to 2.4 mg per deciliter, and the serum albumin level had fallen to 1.5 mg per deciliter (Fig.