Check your medication information with the MKSAP problem, in partnership with the American School of Physicians.

A 28-year-old man is evaluated for a 2-month historical past of progressive lower-extremity edema, weight reduction, and fatigue. Medical historical past is important for leisure use of inhaled cocaine; he denies injection drug use. He has no different identified medical points and takes no drugs.

On bodily examination, temperature is 37.2 °C (99.Zero °F), blood stress is 130/90 mm Hg, pulse fee is 90/min, and respiration fee is 20/min. BMI is 28. Temporal losing is current. The lungs are clear. Cardiac examination is regular, and no pericardial rub is detected. There is no such thing as a hepatosplenomegaly or proof of ascites on belly examination. The decrease extremities present edema to the knees bilaterally. Pores and skin and joint examinations are regular. Delicate asterixis is famous.

Laboratory research:

Albumin 2.5 g/dL (25 g/L)
Liver chemistry research Regular
Blood urea nitrogen 98 mg/dL (35 mmol/L)
Creatinine 6.eight mg/dL (601.1 µmol/L)
Urinalysis 1+ blood; three+ protein; 5 erythrocytes/hpf; Zero-2 leukocytes/hpf
Urine protein-creatinine ratio 3700 mg/g

Kidney ultrasound reveals mildly enlarged and echogenic kidneys with out obstruction.

Kidney biopsy outcomes are indicative of the collapsing variant of focal segmental glomerulosclerosis (FSGS).

Which of the next assessments is most certainly to ascertain the reason for this affected person’s FSGS?

A. Hepatitis B and C serologies
B. HIV antibody take a look at
C. Serum and urine electrophoresis
D. Treponemal antibody take a look at

MKSAP Reply and Critique

The right reply is B. HIV antibody take a look at.

Probably the most applicable take a look at to carry out is an HIV antibody take a look at on this affected person with focal segmental glomerulosclerosis (FSGS). FSGS is the reason for idiopathic nephrotic syndrome in 25% of circumstances. FSGS might also be secondary to a different course of, together with hyperfiltration damage to the glomerulus as might happen in persistent hypertension, diabetes mellitus, and situations during which kidney mass is decreased (progressive kidney illness, weight problems, sickle cell illness, reflux nephropathy, or after nephrectomy). Direct damage to podocytes might also trigger FSGS as seen with sure medication (pamidronate, interferon) and infections, together with HIV. This affected person’s kidney biopsy outcomes are indicative of the collapsing variant of FSGS, which is basic for HIV-associated glomerulopathy. Due to this fact, analysis for HIV an infection as a reason behind this affected person’s FSGS is essentially the most applicable subsequent diagnostic step. Within the early phases of HIV-associated glomerulopathy, antiretroviral remedy and angiotensin system blockers might halt illness development, thus an early analysis is essential.

Hepatitis B is often related to membranous glomerulopathy, and hepatitis C with cryoglobulinemic glomerulonephritis. Serum and urine electrophoresis can be utilized to check for monoclonal gammopathies. The treponemal antibody take a look at is used to check for syphilis, which is often related to membranous nephropathy. None of those problems is related to the collapsing glomerulopathy seen on this affected person’s kidney biopsy.

Key Level

  • HIV an infection is often related to the collapsing type of focal segmental glomerulosclerosis; within the early phases, antiretroviral remedy and angiotensin system blockers might halt illness development.

This content material is excerpted from MKSAP 17 with permission from the American School of Physicians (ACP). Use is restricted in the identical method as that outlined within the MKSAP 16 Digital license settlement. This materials ought to by no means be used as an alternative to scientific judgment and doesn’t symbolize an official place of ACP. All content material is licensed to on an “AS IS” foundation with none guarantee of any nature. The writer, ACP, shall not be chargeable for any harm or lack of any sort arising out of or ensuing from use of content material, no matter whether or not such legal responsibility relies in tort, contract or in any other case.

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