HDCN Article Review/Hyperlink

Thadhani R, Pascual M, Nicheleit V, Tolkoff-Rubin N, Colvin R

Preliminary description of focal segmental glomerulosclerosis in patients with renovascular disease

Lancet (Jan) 347:231-233 1996

These authors carefully reviewed 59 cases of biopsy-proven focal segmental glomerulosclerosis (FSGS) from 1990 - 1995 to investigate a possible association with renovascular disease (RVD). Of 24 patients older than 50 years old, 8 were found to have RVD; none of the 25 patients under 50 had evidence for RVD. The patients had 3.5 - 7.1 grams of proteinuria, but edema, hypercholesterolemia and hypoalbuminemia were rare, supporting a diagnosis of secondary FSGS. The presence of hypertrophied glomeruli without evidence of collapse also was felt to indicate secondary FSGS. Arteriolar hyaline changes were common. A previously unrecognized association between FSGS and RVD was postulated. Renal ischemia leading to compensatory glomerular hypertrophy and secondary FSGS was suggested to be a possible mechanism.

Comment: This interesting possible association between RVD and FSGS has not previously been reported, and bears further examination. However, a chance association may be possible in this series. Some patients were referred for biopsy to assess renal viability prior to renal revascularization or angioplasty; this implies that a population selected for a high incidence of RVD was referred for biopsy. If RVD were truly a cause of secondary FSGS, it is not clear why none of the FSGS patients under 50 years of age had RVD. Finally, in another model of hyperfiltration and glomerular hypertrophy-induced nephrosis, diabetic nephropathy, RVD has been found to be protective against glomerulosclerotic injury in two well documented "experiments of nature," (Beroniade VC, et al. Unilateral nodular diabetic glomerulosclerosis: recurrence of an experiment of nature, Am J Nephrol 7: 55-59, 1987. and Berkman J, Rifkin A: Unilateral nodular diabetic glomerulosclerosis (Kimmelstiel-Wilson): report of a case. Metabolism 22: 715-722, 1973). (Stephen Pastan MD, Emory University)