Background: Focal segmental glomerulosclerosis (FSGS) recurrence after kidney transplantation (KT) is a significant risk factor of graft failure. The recurrence of FSGS develops in 30%–60% of recipients following KT. However, there are few proven clinical markers and risk factors related to FSGS recurrence. To our knowledge, there is no proven evidence for the efficacy of pretransplant conditioning in FSGS. In this study, we evaluated the recurrence rate of FSGS after KT according to pre-transplantation treatment and identified the risk factors associated with recurrence.

Methods: A total of 99 patients who underwent KT due to FSGS at the Asan Medical Center between 2007 and 2018 were included in the study. These patients were divided into the pretreatment group (N = 53) and no pretreatment group (N = 46) according to pretransplant treatment.

Results: The pretreatment group had a significantly shorter dialysis duration than the no pretreatment group (19 vs. 65 months; p < 0.001). FSGS recurrence was less frequent in the pretreatment group [5 (9.4%) vs. 16 (34.8%); p = 0.002]. All three cases of graft failure due to recurrent FSGS occurred in the no pretreatment group. FSGS recurrence after KT was significantly related to age (HR = 0.63, p = 0.014) and pretransplant treatment vs. no treatment (HR = 0.20, p = 0.004). The pretreatment group showed no difference in overall graft survival compared to the no pretreatment group (p = 0.37) but had a superior death censored graft survival (p = 0.04).

Conclusion: The study suggests that pre-transplantation treatment, such as plasmapheresis and rituximab administration, may reduce FSGS recurrence after KT. We recommend preventive plasmapheresis immediately after transplant in patients in whom applying pretransplant treatment was difficult and careful monitoring of such patients for proteinuria.