Loss of living donor renal allograft survival advantage in children with focal segmental glomerulosclerosis

Background. Because of concerns of increased risk of graft loss with recurr ent disease, living donor (LD) transplantation in children with focal segme ntal glomerulosclerosis (FSGS) has been controversial. Methods. The North American Pediatric Renal Transplant Cooperative Study (N APRTCS) database from January 1987 to January 2000 was examined to determin e differences in demographics, treatment, and outcomes in children with FSG S compared with other renal diseases. Results. Data on 6484 children, 752 (11.6%) with FSGS, demonstrated that FS GS patients were more likely to be older and black, and were less likely to receive either pre-emptive or LD transplant (P < 0.001). No differences ex isted in human lymphocyte antigen (HLA) matching or immunosuppression regim ens. Acute tubular necrosis occurred in more FSGS patients following LD (11 .8 vs. 4.6%) or cadaveric (CD; 27.9 vs. 16.3%) transplants (P < 0.001). Gra ft survival was worse for LD FSGS patients (5 years 69%) compared with no F SGS (82%, P < 0.001) and was not significantly different than CD graft surv ival in the FSGS (60%) and No FSGS groups (67%). The LD to CD ratios of rel ative risk of graft failure were higher in FSGS patients (test for interact ion, P = 0.01). Recurrence of original disease was the only cause of graft failure that differed between groups (P < 0.001). A greater percentage of L D FSGS graft failures was attributed to recurrence (P = 0.06). Conclusions. The impact of FSGS on graft survival in children is greatest i n LD transplants, resulting in loss of expected LD graft survival advantage . The rationale for LD grafts in children with FSGS should be based on fact ors other than better outcomes typically associated with LD transplantation .