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Focal segmental glomerulosclerosis in the transplanted kidney

Nada Alachkar, MD
Daniel C Brennan, MD, FACP
Andre A Kaplan, MD
Christopher H Kwoh, MD
Section Editor
Barbara Murphy, MB, BAO, BCh, FRCPI
Deputy Editor
Albert Q Lam, MD


Focal segmental glomerulosclerosis (FSGS) is a histologic pattern of injury in the kidney that may have multiple different etiologies, including genetic diseases, infection, toxins, and obesity, as well as previous injury resulting in hyperfiltration of remaining viable nephrons. (See "Epidemiology, classification, and pathogenesis of focal segmental glomerulosclerosis", section on 'Classification'.)

Primary idiopathic FSGS, which occurs in the absence of a known etiology, commonly progresses to end-stage renal disease (ESRD). When transplantation is performed, primary idiopathic FSGS may recur in the renal allograft.

An overview of FSGS in the renal allograft is presented in this topic review. The pathogenesis and treatment of FSGS in the native kidney are discussed elsewhere. (See "Epidemiology, classification, and pathogenesis of focal segmental glomerulosclerosis" and "Treatment of primary focal segmental glomerulosclerosis".)


FSGS in the allograft may be recurrent or de novo. Both recurrent and de novo FSGS may be primary idiopathic or related to known causes, such as infection, toxin exposure, genetic mutation, or obesity. In addition, FSGS may develop as a result of hyperfiltration injury related to loss of functioning kidney parenchyma; this form of FSGS is traditionally called secondary FSGS. In this review, FSGS related to a known cause other than hyperfiltration is referred to as primary non-idiopathic FSGS. FSGS that is without a known cause is called primary idiopathic FSGS. The term secondary FSGS is reserved for FSGS that is due to hyperfiltration injury.


The rate of recurrence of primary idiopathic FSGS is difficult to ascertain since it is often not clear whether the patient had primary idiopathic FSGS or FSGS related to other causes as the initial cause of end-stage renal disease (ESRD). Although the reported FSGS recurrence rate averages approximately 30 percent [1-11], it is likely that some of the patients in these studies had FSGS due to a toxin, viral infection, or hyperfiltration injury that would not be expected to recur in the transplant. Thus, the rate of recurrence among patients with primary idiopathic FSGS may be higher than 30 percent. There is, for example, a subgroup in which the disease recurs in approximately one-half of cases. These patients, who almost certainly have primary idiopathic FSGS, tend to be <20 years of age and to have had a rapid clinical course, with the interval from diagnosis of FSGS to ESRD being less than three years [1,4,12,13].


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Literature review current through: Sep 2016. | This topic last updated: Aug 24, 2016.
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