Focal and Segmental Glomerulosclerosis

Abstract

Focal and segmental glomerulosclerosis (FSGS) is one of the most common primary glomerular diseases to terminate in ESRD.A complete remission (CR) confers an excellent long-term prognosis, but the quantitative benefits of partial remissions (PR) have not been defined. This study evaluated the rate of renal function decline (slope of creatinine clearance) and renal survival in nephrotic FSGS patients with CR, PR, or no remission. It also examined relapse rate from remission and its impact on outcome. Multivariate analysis included clinical and laboratory data at presentation and over follow-up, BP control, the agents used, and immunosuppressive therapy. The study cohort was 281 nephrotic FSGS patients who had a minimum of 12 mo of observation and were identified from the Toronto Glomerulonephritis Registry. Over a median follow-up of 65 mo, 55 experienced a CR, 117 had a PR, and 109 had no remission. A PR was independently predictive of slope and survival from renal failure by multivariate analysis (adjusted time-dependent hazard ratio, 0.48; 95% confidence interval, 0.24 to 0.96; P ‫؍‬ 0.04). Immunosuppression with high-dose prednisone was associated with a higher rate of PR and CR. Relapse from PR was frequent (56%) and associated with a more rapid rate of renal function decline and worse renal survival compared with relapse-free partial remitters. Only female gender and the nadir of proteinuria during remission were associated with a sustained remission. A PR in proteinuria and its maintenance are important therapeutic targets in FSGS, with implications for both slowing progression rate and improving renal survival.J (FSGS) is one of the most common causes of primary glomerular disease that terminates in renal failure (1,2). In most series, its 10-yr survival is in the 40 to 60% range (3-7).Severity of proteinuria at onset and during follow-up have been associated with a poor outcome in several series (3-8).Although there is strong evidence that nephrotic patients who experience a complete remission (CR) have a very favorable prognosis (9 -11), the long-term outcome in adults with only a reduction in proteinuria has seldom been reported (11,12). Despite the lack of evidence of its value as a valid surrogate for improved renal survival in FSGS, it is often reported as a positive finding in clinical studies (11)(12)(13)(14).This study addresses the long-term implications of a partial remission (PR) in nephrotic FSGS patients. It compares the rate of renal function decline, relapse, renal failure, and treatment effects among patients with a PR, CR, and no remission (NR). Materials and MethodsAll FSGS patients from the Toronto Glomerulonephritis Registry were considered for this study. This database began in 1974 and includes all biopsy-proven cases of glomerulonephritis from the Toronto area. Patient information at onset is compiled using a standard form, and registrars perform a periodic prospective assessment of the patients' clinical status, medications, and laboratory results (15). We reviewed all previous m...

Circulating suPAR in Two Cohorts of Primary FSGS

“…Decreasing suPAR is also associated with greater odds of achieving complete remission. 18 These findings are based on analysis of proteinuria as a continuous rather than a discrete variable, as was done in the evaluation of efficacy in the FSGS CT cohort. 19 We acknowledge that our findings from the FSGS CT are exploratory in nature because suPAR was assayed in a subset of the total study cohort and patients could be withdrawn from the study if there was no evidence of response after 26 weeks.…”

Clinical Features and Outcomes of IgA Nephropathy with Nephrotic Syndrome

“…In these patients, the risk reduction for the primary outcome was much greater than those in the NR group. The importance of PR has been suggested for various glomerulopathies (1,21,22). In particular, Reich et al indicated that patients with IgAN who initially presented with proteinuria .3 g/d and achieved PR (,1 g/d) had similar outcomes to patients with persistent proteinuria of ,1 g/d during follow-up and also had superior prognoses to patients who never achieved remission (1).…”

APOL1 Genetic Variants in Focal Segmental Glomerulosclerosis and HIV-Associated Nephropathy

“…Glucocorticoid sensitivity was defined as complete or partial remission in subjects who had received at least 8 wk of daily or alternate-day glucocorticoid therapy. 26 Glucocorticoid sensitivity was evaluable for 56 African Americans with FSGS (26% of the total number of cases); the other subjects did not receive the required course of glucocorticoids.…”