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Kidney Week

Abstract: PO2210

Use of Lipoprotein Apheresis in Recurrent Focal Segmental Glomerulosclerosis Following Transplant

Session Information

Category: Transplantation

  • 1902 Transplantation: Clinical


  • Campbell, Ruth E., University of Colorado, Denver, Colorado, United States
  • Grafals, Monica, University of Colorado, Denver, Colorado, United States

Primary focal segmental glomerulosclerosis (FSGS) recurs in 20-50% of transplanted kidneys and has a high rate of transplant failure. We report a case of recurrent FSGS treated with lipoprotein apharesis (LDL-A)

Case Description

A 27 year-old male with primary FSGS underwent a DBD kidney transplant. He was ESRD on PD and anuric. ATG and steroids were given for induction. On post-op day (POD) 2, his spot urine protein was > 2000 mg (unable to calculate urine protein/creatinine ratio (UPCR)). Serum creatinine was 1.47 mg/dL (pre-transplant: 9.65 mg/dL). With concern for recurrent FSGS, emergent therapeutic plasma exchange (TPE) and losartan were started. On POD 3 and 4, proteinuria was > 2,000 mg; TPE was done daily and adrenocorticotrophic hormone (ACTH) and rituximab started. Despite 5 days of TPE and medical therapy, proteinuria was > 2,000 mg. On POD 8, LDL-A was started. Prior to second LDL-A run, his proteinuria was 1990 mg but 294 mg afterwards. Proteinuria rebounded between treatments, but steadily decreased: by week 3, UPCR was 686 mg/g and by final LDL-A, was 200 mg/g. Renal function was stable and biopsy had no podocyte effacement. He completed LDL-A biweekly for 3 weeks, then weekly for 6 weeks. ACTH and rituximab were continued. Currently, his UPCR is 9 mg/g.


Treatment of recurrent FSGS centers on plasma exchange and immunosuppression. By lowering LDL levels, LDL-A is thought to reduce proteinuria by reducing vascular permeability and improving response to immunosuppressive agents. Case reports indicate efficacy, but currently the use of LDL-A is designated as a humanitarian device exemption for drug resistant recurrent FSGS in transplanted kidneys by the FDA. Although this modality is uncommon, our case suggests that patients with recurrent FSGS may benefit from early initiation of LDL-A.