Combined rituximab and plasmapheresis or plasma exchange for focal segmental glomerulosclerosis in adult kidney transplant recipients: a meta-analysis

Purpose: To demonstrate the efficacy of combined rituximab and plasmapheresis (PP)/plasma exchange (PE) therapy for focal segmental glomerulosclerosis in transplanted kidneys (ptFSGS). Methods: We searched MEDLINE, SCOPUS, and Cochrane Library for eligible publications. Only observational studies or clinical trials containing patients’ age > 18 years were included for full-text extraction. Results: A total of eight observational studies (n = 85) were included in meta-analyses. With a median follow-up of 18 months (IQR 4.4), combination therapy of RTX-PP/PE in patients with ptFSGS resulted in overall remission rate of 72.7% (95% CI 52.3–86.6%) with a significant reduction of proteinuria and serum creatinine levels. Complete remission was 41.0%, while partial remission was 31.7%. The mean difference of serum creatinine levels between pre- and post-treatment was − 0.65 mg/dL (95% CI − 1.15 to − 0.14). The mean difference of the degree of proteinuria between pre- and post-treatment was − 4.79 g/day (95% CI − 7.02 to − 2.56). Subgroup analyses were performed after adjusted for study year, type of intervention, and primary pre-transplant lesion. Patients with recurrent FSGS tended have lesser reduction in the degree of proteinuria compared to patients with de novo FSGS. Incidence of serious adverse events with combined RTX-PP/PE therapy was 0.12 event/year. Conclusion: We conclude that combined RTX-PP/PE therapy may be considered as an alternative treatment of ptFSGS in achieving remission by lowering proteinuria and serum creatinine levels. However, the efficacy of combined RTX-PP/PE therapy must be confirmed in randomized-controlled trials.