Discussion: Primary Nephrotic Syndrome

Abstract

Related to the problem of recurrence in transplants, we talked about recurrence of disease in FSS versus membranous proliferative. The recurrences in focal sclerosing are very complicated recurrences; they look a bit like chronic rejection. It is very difficult to tell whether one has late chronic rejection or true recurrence of focal sclerosis, unless one has the type of situation where proteinuria appears within a day or two. In two of our patients we have even seen actual proteinuria on the operating table at the time of the transplant, proteinuria in the first urine that comes out of the new kidney. In type II membrano-proliferative, where there is said to be a lot of recurrences, the recurrences consist of the presence of intra-membranous ribbon-like material within the basement membrane (tubular and glomerular). However, the clinical implication of this is not so severe; many of these patients do not have evidence of progressive renal disease, and in fact, do quite well. We have had the opportunity to do repeat biopsies in two patients who have recurrent type II MPGN; they have not had any decline in renal function. That is an important distinction. The fact that we get these intra-membranous deposits is an interesting observation but they may not mean that much in terms of the actual clinical course of the patient, at least over the four or five years of follow-up that we and other people have documented.