The Differential Effect of Race Among Pediatric Kidney Transplant Recipients With Focal Segmental Glomerulosclerosis Kui Huang, MPH, Maria E. Ferris, MD, MPH, Kenneth A. Andreoni, MD, and Debbie S. Gipson, MD ● Background: Given the differential effect of race on focal segmental glomerulosclerosis (FSGS) progression in native kidneys, recurrence of FSGS in the transplanted kidney, and allograft source, the authors conducted this study to evaluate the influence of FSGS by race and allograft source. Methods: Data from 8,065 pediatric renal transplant recipients (n  620 FSGS) between 1987 and 1997 from the United Network for Organ Sharing registry were used for this study. Stratified analysis by race and allograft source allowed independent assessment of the effect of FSGS on transplant survival. Results: Among black children, allograft survival was not different between FSGS and non-FSGS patients adjusted for recipient age, recurrent disease, allograft source, zero antigen mis- match, and acute rejection (hazard ratio [HR], 1.15; 95% confidence interval [95% CI], 0.93 to 1.42; P  0.22). Among nonblack children, the risk of allograft failure in children with FSGS was 1.31 times higher than other causes of end-stage renal disease (ESRD) in multivariate analysis (95% CI, 1.04 to 1.64; P  0.02). Despite the impact of disease recurrence in the nonblack children with FSGS, the risk of graft failure was less for living donor recipients (HR, 1.51; 95% CI, 1.08 to 2.10) than for cadaveric recipients (HR, 1.80; 95% CI, 1.32 to 2.44) compared with the lowest risk group (nonblack, non-FSGS, living donor). Conclusion: The effect of FSGS on renal allograft survival in children differs between racial groups. Children of nonblack races with FSGS have a worse allograft survival rate compared with other causes of ESRD. Within nonblack children with FSGS, living donor transplants convey a better allograft survival than cadaveric transplants. Am J Kidney Dis 43:1082-1090. © 2004 by the National Kidney Foundation, Inc. INDEX WORDS: Pediatric; focal segmental glomerulosclerosis (FSGS); transplant. F OCAL SEGMENTAL glomerulosclerosis (FSGS) is a leading cause of proteinuria and kidney disease in children and adolescents. This disorder affects black Americans more com- monly than any other racial or ethnic group in the United States. 1-3 Compounding this disease sus- ceptibility, black Americans with FSGS have a greater risk of progression to end-stage renal disease (ESRD) compared with children of other races. 4-6 Among those who proceed to renal transplan- tation, recurrence of FSGS has been documented to occur more commonly among children of nonblack races (nonblack 41% v black 10%). 7 Additional published studies in the past decade identified a greater risk of FSGS recurrence among kidney transplant recipients of a living donor graft compared with a cadaveric graft. Consequently, recommendations were made to avoid living donor organs for patients with FSGS. 8-12 Given the improved allograft survival rate with living donor organs and the current cadaveric organ shortage, this recommendation was controversial. Subsequent data from the North American Pediatric Renal Transplant Co- operative Study suggested that allograft survival was similar for children with FSGS among cadav- eric and living donor transplant recipients. 10,13 The frequency of allograft failure caused by recurrent FSGS was approximately 6% of this pediatric cohort. 10,13 Beyond disease-specific effects, an associa- tion between race and organ source has been observed in both pediatric and adult patient popu- lations. Black Americans are more likely to re- ceive a cadaveric organ and patients of other races a living donor organ. 14 Generally, the living donor kidney transplants have been linked with a longer median allograft survival rate when com- pared with cadaveric organs. 15 Given the differential effect of race on disease in the native kidney, recurrence of disease in the transplanted kidney and organ source (living or cadaveric), it is difficult to clearly interpret the predictors of kidney transplant survival in chil- dren with FSGS. The purpose of this study was From the Division of Nephrology and Hypertension and the Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC. Received November 11, 2003; accepted in revised form March 8, 2004. Address reprint requests to Debbie S. Gipson, MD, Divi- sion of Nephrology & Hypertension, 349 MacNider Hall, Campus Box 7155, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7155. E-mail: debbie_ gipson@med.unc.edu © 2004 by the National Kidney Foundation, Inc. 0272-6386/04/4306-0017$30.00/0 doi:10.1053/j.ajkd.2004.03.017 American Journal of Kidney Diseases, Vol 43, No 6 (June), 2004: pp 1082-1090 1082