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Anjali Gupta 12/28/11
FSGS most common cause( 57%) of nephrotoc syndrome in AA
FSGS is the most
common cause of GN related ESRD
Familial-Genetic Alpha-actin4 Podocin
Virus –Associated HIV associated Parvovirus B-19
Drug-med Heroin Pamidronate
Reduced Renal Mass Unilateral renal agenesis Reflux nephropathy
Initial normal renal mass Obesity Atheroembolic Sickle cell Anemia
Obesity Related 1. Low grade proteinuria 2. Slow progressive increase
in proteinuria 3. Usually asymptomatic
and not nephrotic 4. Obese with no family
history 5. Slow progression to ESRD 6. Glomerulomegaly on
biopsy 7. Do not have 100%
effacement of podocytes
Idiopathic 1. Massive proteinuria 2. Acute onset nephrotic
syndrome 3. Faster progression to
ESRD 4. No glomerulomegaly 5. 100% foot process
effacement
Foot process effacement In a systematic study of podocyte alterations mean
percentage of the glomerular surface area affected by foot process fusion was
42% +22% in obesity associated FSGS
compared with classic FSGS (65% + 23%) Although helpful, the semi-quantitative assessment of foot
process fusion thus does not provide an absolute means for distinguishing between these primary and secondary forms.
Mod Pathol 7:157A, 1994 Barasoni et all
17 patient with idiopathic and 12 patients with secondary causes of FSGS based on clinical criterion evaluated.
Kidney International (2008) 74, 1568–1576
Serum Albumin Retrospective study 37 pt with biopsy proven FSGS and persistent nephrotic
syndrome were dived base on albumin levels prior to biopsy Gp1 <3 gm/dl and Gp2 with >3.5gm/dl.
All patients in Gp 1 were diagnosed of i FSGS and all expect 2 patients were in Gp 2 were diagnosed of sec FSGS ( 44% Obese, 27% had vesicoureteral refkex and 13% had reduced renal mass.
Gp 2 patients had significant glomerulomegaly.
American Journal of Kidney Diseases, Vol 33, No 1 (January), 1999: pp 52-58
Renal survival in patients with obesity‐associated FSG (OB‐FSG) and idiopathic FSG (I‐FSG).
Praga M et al. Nephrol. Dial. Transplant. 2001;16:1790-1798
European Renal Association-European Dialysis and Transplant Association
Clinical Proteinuria/ Nephrotic syndrome AA race
Histopathology Interstitial fibrosis Tip lesion Collapsing FSGS
Course Remission of proteinuria
Toronto registry examined 281 FSGS patients
Median follow up of 5 years
J Am Soc Nephrol 16: 1061-1068, 2005.
• No randomized trials to guide the dose and duration of glucocorticoid
therapy
• Multiple retrospective studies showed Complete Remission form 32-47% and partial remission 20- 26 % ( Agarwal 1993, Pontechilli 1999, Chun 2004 ) • Dose 0.5-1 Kg/day. High dose usually 2-3 months with total duration of 6-
9 months • Median time to remission 3.7- 5months • In Pontechilli study if steroid duration was <16 weeks Remission was 16%
as compared to 61% if duration was >16 weeks
• 33 Nephrotic FSGS after 6
months of ACE n ARB • Therapy Gp A: MMF Ig BID * 6 months
+ Steroids 0.5mg/kg/day * 3months
Gp B: Steroids 1 mg/kg/day *
3-6 months Relapse rate 4 in each
patient
Response in 5-10 weeks Nayagam: NDT 2008 23: 1926-30
Steroid resistance : Children 8 weeks of therapy and adults 16 weeks of steroids. 40-70% of FSGS pts are steroid resistant
Steroids Calcineurin Inhibitors Cyclosporine Tacrolimus Cytotoxic agents Cyclophosphamide MMF
Cyclosporine
•RTC of 49 steroid resistance FSGS cases comparing 26 weeks of cyclosporine and low dose prednsione with placebo and prednsione
•Relapse was common after cyclosporine withdrawal (40 and 60 percent had worsening of proteinuria by week 52 and 78, respectively). •At four years, active therapy was associated with a lower risk of a 50 percent reduction in creatinine clearance (25 versus 52 percent).
MMF vs cyclosporine in FSGS
Prospective , randomized, multi-center, open label trial Compared MMF with cyclosporine Enrolled 138 pts (initial plan for 500) Age 2-40 years E GFR > 40 , u p/cr >1gm/g Corticosteroid resistant defined as >4 weeks of steroids
Cyclosporine 5-6 mg/kg to maintain levels
of 100-250 ng/ml
(max dose 250)
MMF + Dexa MMF 25-35 mg/kg (max 2gm/day)
Dexa 0.9mg/kg
Weekly , biweekly n then monthly
Total 46 doses
Both Groups: Prednisone 0.3mg/kg (max 15mg ) * 6 months Ace inhibitor for 18 months
MMF (N=66) Csa( n =72) O R CI
CR 26 2 (3.0) 4.0(5.6) 0.53 0.09-3
CR 52 4 (6.1) 10(13.9) 0.41 0.15-1.15
PR 16(24.2) 19(26.4) 0.59 0.30-1.18
CR+PR 22(33.3) 33(45.8) 0.59 0.30-1.18
Relapse rate at 78 weeks : 33% in Csa vs 17 % in MMF Adverse events: •Infections 13.6 in Csa Vs 9.7% in MMF •Both groups hospitalization 25-27% and Gi side affects ~ 70 %
Results
60% patients were less than <18 years Underpowered study Definition of corticosteroid resistant Pt with sub nephrotic proteinuria included
Thank you
Results
Chlorambucil