A 27-year-old HIV positive man comes for a re-visit after a screening urinalysis reveals strikingly elevated protein levels. The patient is currently reluctant to start antiretroviral therapy, though he is taking prophylactic antibiotics. He has a distant history of injection drug use. On exam, the patient has mild ankle edema and is slightly cachectic, but otherwise appears well. A new urinalysis reveals 3+ proteinuria without any hematuria or red cell casts. A serum albumin is 2.3 g. Which disease process is most likely to explain this patient’s proteinuria?
Minimal change disease
Focal segmental glomerulosclerosis
Membranoproliferative glomerulonephritis
Membranous nephropathy
IgA nephropathy
Correct answer
Focal segmental glomerulosclerosis
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correct answer: B
This patient’s clinical description is that of nephrotic syndrome. Nephrotic syndrome is characterized by proteinuria without hematuria; other manifestations may include edema, thrombosis, infection, low serum albumin, coagulopathy, and hyponatremia.
Patients with HIV and no other diseases are particularly likely to have a variant of focal segmental glomerulosclerosis (FSGS) called HIV-associated nephropathy (HIVAN). This is especially true among black patients.
Minimal change disease is the most common nephrotic glomerular disease in children.
Membranous nephropathy is the most common nephrotic glomerula disease in adults, especially those with lupus or Hepatitis B.
Membranoproliferative glomerulonephritis and IgA nephropathy both result in nephritic syndrome, characterized by microscopic hematuria.