A 23-year-old female with primary focal segmental glomerulosclerosis (FSGS), diagnosed at the age of 16, underwent a living-related kidney transplantation (KT). She was on hemodialysis for 2 years before transplant but still had residual urine output of 500 mL/day with a random urine protein-to-creatinine ratio (UPCR) of 1.5 g/gCr. On post-operative day 4, UPCR was noted as 14 g/gCr. A kidney allograft biopsy demonstrated diffuse effacement of podocyte foot processes with no evidence of acute rejection.
What are the risk factors and mechanisms of recurrent primary FSGS posttransplant? What treatment options (pre- and posttransplant) might benefit this patient?