A 29-year-old patient with focal segmental glomerulosclerosis (FSGS) and recurrence of the disease in a living donor kidney transplant received a second living-related kidney graft. She received pre- and postoperative immunoadsorptions and immunosuppression with tacrolimus, mycophenolate mofetil, basiliximab and steroids. Serum creatinine returned to normal values and only minor proteinuria was detected post-transplant (400 mg/24 h). However, recurrence of proteinuria with up to 3.3 g/24 h occurred 2 months after transplantation and the patient underwent intermediate immunoadsorption sessions with immediate reduction of proteinuria for the following year. She then received three doses of rituximab (600 mg, 375 mg/m(2)) that caused immediate reduction of proteinuria with only minimal increase in the following 12 months. Graft function is excellent 2 years after transplantation. These findings suggest that intermittent immunoadsorption combined with B-cell depletion by rituximab treatment induced prolonged reduction of proteinuria in a high-risk patient for recurrence of FSGS in the graft.