Post on 27-Sep-2020
DrKirstyArmstrongConsultantNephrologistandLeadforYoungPa;entsWessexKidneyCentre,QueenAlexandraHospital,PHT
UniversityHospitalNHSTrust
RelapsedFSGSPost-Transplant…..Again…..
WhatNext?
Thejoysofyoungadults!
Thejoysofyoungadults!
RR20/1/2000
• 03/12PresentedtoPaeds;PCR2933– SRNS–failedresponsetohighdoseprednisolone– Bx–2/29globallysclerosedgloms;segmentalsclerosis;minorIFTA
– Nega;vegene;ctes;ng– CNI-3/12–noresponse– MMF+CNI–5/12–noresponse– 01/14startedHD(Cr640)
RR20/1/2000
– 03/14Le]nephrectomy– 04/14Rightnephrectomy– 05/14HHD– 01/15LURT;011mm
• Aza/Pred/Tac
RR20/1/2000
– 4/16–risingcrea;nine(100)andPCR(392)• Bx:?possible;plesions• Confirmedrelapse–startedonPEX• 2000HAS2200octeplase;dailytreatment
– 06/16to12/16–weeklyPEX;PCR<30– 12/16–rituximabx2;PCR215– 02/17–PCR<30
• Weeklytreatment
RR20/1/2000– 08/17Relapse(PCR150)
• 1.5volumeexchangesevery2/52• Doubleexchanges3/week+rituximab• Weeklytreatment
– 02/18Relapse• 2/week→3/week→ 1/week• ↑ PCRwith↓ frequency
– 09/18PlymouthUni– 12/18–LDLapharesis12sessionsover9/weeks
• KanekaLiposorberLA-15system• StartedatUHSandcompletedatPlymouth
RR20/1/2000
– 12/18-TransfertoWKC– 01/19to04/19–treatmentatPlymouth
• 2/weekexchanges(PCR100-200)→ 3/week
– 04/19to10/19• 2/weekexchanges–PCR<50• 05/19–clokedAVF• 07/19to08/19–PEXatDorchester• 08/19-LUAPTFE• 09/19-TransferredcoursetoPortsmouthUni
RR20/1/2000
– 10/19….relapse..• PCR16→ 771over7/7
Rituxumab
FrequencyofTPE
2x/week DailyAltday
3x/week
2x/week
3x/week
RR20/1/2000
– Currentsitua?on• 2/weekexchangesince8/1/20• Prescrip;on:4LHAS200octaplas• Cr68,Alb35-40• PCR~700(peak2560)andstable
RR20/1/2000
“Sincemyfirstrelapseposttransplant,therehasneverbeena;methatIwascompletelyofftreatment.TherewasashortperiodwhenIonlyneededplasmaexchangeonceeveryotherweektokeepmeinremission.“Thatsoundslikeheaventomenow…”
RR20/1/2000
WHATNEXT?
RR20/1/2000
• Con;nuewithtwiceweeklyplasmaexchange?• Re-dosewithrituximab?– Ifanotherrelapse?– Rou;nelya]er6months?
• TransplantnephrectomyandHHD?• Alterna;vetherapies– ofatumumab
Ofatumumab
Ofatumumab