Abstract: SA-PO1193
Recurrent Lipoprotein Glomerulopathy After Repeat Kidney Transplant Despite Lipid-Lowering Therapy
Session Information
- Transplantation: Clinical - Complications, Pediatrics, and Multi-Organ Considerations
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Gutierrez, Omar, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
- Nori, Uday S., The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
Introduction
Lipoprotein glomerulopathy (LPG) is a rare genetic disorder characterized by lipoprotein thrombi within glomerular capillaries, nephrotic range proteinuria, and progressive renal failure. It is most commonly associated with mutations in the APOE gene, including the APOE Kyoto (Arg25Cys) variant, which impairs lipoprotein clearance. Although kidney transplantation is often performed in patients who progress to end stage renal disease (ESRD), recurrence of disease in the allograft has been reported, supporting the role of circulating pathogenic factors. We present a case of recurrent LPG following two kidney transplants, including recurrence despite aggressive lipid lowering therapy.
Case Description
A 45 year old man with heterozygous APOE Kyoto mutation developed ESRD from FSGS in the setting of lipoprotein glomerulopathy (LPG). He received his first deceased donor transplant at age 33, initially stable but later complicated by nephrotic range proteinuria, rising creatinine, and de novo anti HLA antibodies. Biopsy showed recurrent LPG with lipoprotein thrombi and transplant glomerulopathy; he was treated with IVIG, steroids, and mycophenolate, but the graft failed after six years, requiring return to dialysis. At age 42 he underwent a second transplant with good early function and was started on intensive lipid lowering therapy (evolocumab, rosuvastatin, fenofibrate), achieving LDL <30 mg/dL. Despite excellent lipid control, his creatinine rose two years later, and biopsy again demonstrated recurrent FSGS with focal lipoprotein microthrombi, consistent with recurrent LPG.
Discussion
This case shows recurrent LPG after two kidney transplants, including recurrence despite intensive lipid lowering therapy. The findings emphasize that LPG is a systemic apoE driven disorder rather than a consequence of dyslipidemia or intrinsic renal pathology. The APOE Kyoto variant disrupts LDL receptor binding and endothelial uptake, causing persistent circulating lipoproteins and glomerular deposition. Notably, disease returned despite well controlled lipid levels on PCSK9 inhibitor, statin, and fibrate, indicating that lowering lipid quantity alone cannot prevent recurrence when apoE structure is abnormal.
Teaching Points: 1. Lipoprotein glomerulopathy is a systemic APOE driven disease, so recurrence can occur after transplant even with excellent lipid control.