Double recurrence of FSGS after two renal transplants with complete regression after plasmapheresis and ACE inhibitors

A patient who had undergone a first cadaveric donor kidney transplantation for idiopathic focal segmental glomerular sclerosis (FSGS), had an immediat e recurrence of a biopsy-proven FSGS that eventually led to graft failure w ithin 5 years from transplantation. The patient underwent a second cadaveri c transplantation 10 months later. An immediate recurrence of a biopsy-prov en FSGS occurred that was treated with two protracted cycles of plasmaphere sis of seven months each, with the addition of an ACE inhibitor from the be ginning. A complete and stable remission of FSGS was observed, which contin ues after more than 6 years from the end of plasmapheresis. The recurrence of FSGS after a second transplantation has a poor prognosis, but: prolonged plasmapheresis treatment, by removing circulating factors altering glomeru lar permselectivity, and the addition of ACE inhibitors, through their pote ntial interference with TGF-P, might be synergistic in obtaining permanent remission.