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Even in the case of steroid resistance minimal change nephritic syndrome (MCNS), Yang et?al. (22) showed that the permeable factor could be produced by B- or T cells through pathways http://www.selleckchem.com/HSP-90.html regulated or stimulated by B cells. B cells may thus be a source of this permeable factor, directly or indirectly causing damage to glomerular epithelial cells. In this patient, rituximab was given in combination with PE, so the efficacy of rituximab alone was impossible to determine. We still cannot exclude the contributions of PE and combined MMF, tacrolimus, and ARB to sustained remission of FSGS. By the three-month protocol biopsy, proteinuria had actually decreased with foot process recovery (Fig.?2B) before PE. Remission might be achieved without PE and rituximab. We should be careful to make a decision to treat such a nephritic (not nephrotic) transplant patient to avoid over-immunosuppression. Even with widespread application of plasmapheresis for recurrent FSGS, relapse rates remain high, and patients may become plasmapheresis dependent (1, 2). In the case of preemptive plasmapheresis, some reports have indicated trends toward reductions in recurrence rates and a resulting improvement in graft survival benefit among high-risk patients (8, 9). According to a literature review (Tables?3 and 4), preemptive plasmapheresis seemed to provide better outcomes for remission of FSGS when conducted along with use of rituximab. Preemptive plasmapheresis was used in 33% of effective cases, compared to 15% of ineffective cases (Table?4). The combination of preemptive plasmapheresis and rituximab may be a future strategy for recipients with FSGS as the original disease, using preemptive plasmapheresis for prevention and rituximab for treatment. Plasmapheresis is usually first initiated when recurrence of FSGS is confirmed, with rituximab considered next. Lesions of FSGS develop only after several weeks as a consequence of persistent proteinuria. According to the literature, time between FSGS onset and rituximab may play an important role in reducing proteinuria (Table?4). We defined efficacy of plasmapheresis and rituximab in these cases as proteinuria reaching and continuing at