Abstract: FR-PO739

A Patient with “Albumin-Dependent” Focal Segmental Glomerulosclerosis

Session Information

Category: Glomerular

  • 1004 Clinical/Diagnostic Renal Pathology and Lab Medicine


  • Duffy, Margaret, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
  • Palmer, Matthew, University of Pennsylvania, Philadelphia, Pennsylvania, United States
  • Potluri, Vishnu S., The University of Pennsylvania, Philadelphia, Pennsylvania, United States
  • Hogan, Jonathan J., The University of Pennsylvania, Philadelphia, Pennsylvania, United States

Idiopathic focal segmental glomerulosclerosis (FSGS) can present with severe volume overload and acute kidney injury (AKI). Here we present such a patient with idiopathic FSGS complicated by multiple episodes of severe AKI and diuretic-resistant volume overload that was only responsive to IV albumin therapy.


A 54 year-old Jamaican woman developed nephrotic syndrome (SCr 0.86 mg/dL, UProt:Cr 8 g/g, SAlb 1.7 g/dL). A kidney biopsy revealed tip-variant FSGS. She achieved partial remission within four weeks with prednisone 120 mg/d, but then relapsed (UProt:Cr 3.6, SAlb 2.1 g/dL). She was hospitalized with oliguric AKI (Scr 3.89 mg/dL) and volume overload refractory to high-dose IV diuretics and developed candida esophagitis and C. difficile colitis. Steroids were tapered and she was treated with IV albumin (25%, 1 mg/kg q8h), with improvement in her SCr (1.37 mg/dL) and urine output (8L) within 24 hours (see image). Tacrolimus was started and she was discharged.
She was then re-admitted for volume overload, hypoalbuminemia, and AKI that only responded to 25% IV albumin. Tacrolimus levels were undetectably low. We hypothesized that her acute anasarca led to her inability to absorb tacrolimus. We therefore treated her aggressively with 5 sessions of intermittent ultrafiltration, 5 sessions of plasma exchange therapy with albumin replacement, and pulse oral dexamethasone (40 mg/week). Her AKI again resolved and she was discharged on weekly dexamethasone, oral tacrolimus, and biweekly outpatient albumin infusions. With this therapy she achieved complete remission with target tacrolimus trough levels 6-8 µg/L. She was weaned off steroids and IV albumin. She has been in complete remission for five months on tacrolimus monotherapy.


We present a case of idiopathic FSGS with a rare and extreme phenotype of severe volume overload and recurrent AKI. In these cases, IV albumin therapy should be considered, particularly for patients who were previously steroid-responsive and may therefore be responsive to other immunosuppressive agents.