A 43-year-old African-American man with known HIV is evaluated for edema. A diagnosis of HIV was established five years ago and HAART therapy initiated, but he has been non-compliant due to side effects. He began experiencing leg edema 3 months ago that has progressively increased in severity.
His temperature is 36.6 C (97.9 F), blood pressure is 130/82 mm Hg, and pulse is 84/min. Cardiac, pulmonary, and abdominal examinations are unremarkable. He has 3+ ankle edema that extends to the knees and 1+ presacral edema.
His laboratory studies are shown below.

Which of the following would you expect to see on kidney biopsy?

Question

A 43-year-old African-American man with known HIV is evaluated for edema.  A diagnosis of HIV was established five years ago and HAART therapy initiated, but he has been non-compliant due to side effects.  He began experiencing leg edema 3 months ago that has progressively increased in severity. 
His temperature is 36.6 C (97.9 F), blood pressure is 130/82 mm Hg, and pulse is 84/min.  Cardiac, pulmonary, and abdominal examinations are unremarkable.  He has 3+ ankle edema that extends to the knees and 1+ presacral edema.
His laboratory studies are shown below.

Which of the following would you expect to see on kidney biopsy?

Quizplus · Accepted Answer

This patient's clinical presentation is most suggestive of HIV-associated nephropathy, which is focal segmental glomerulosclerosis (FSGS) of the collapsing histologic type. FSGS mainly occurs in African-Americans, HIV patients with low CD4 counts and high viral loads, and in patients exposed to toxins such as heroin. FSGS in HIV-infected individuals is associated with large echogenic kidneys on ultrasound, few red or white blood cells on urinalysis, heavy proteinuria, and hypoalbuminemia. Surprisingly, hypertension is not seen despite the high incidence of hypertension seen in African Americans. In patients with well-controlled HIV due to HAART, FSGS continues to occur, but the clinical course is more indolent - normal sized kidneys, less proteinuria and a slow decline in glomerular filtration rate. The progression of disease can be decreased with HAART therapy, ACE inhibitors, or angiotensin receptor blockers to reduce proteinuria, and possibly steroids in some cases. (Choice B) IgA-associated glomerulonephritis can occur in HIV patients, but the lack of red blood cells and red blood cell casts on urinalysis makes this diagnosis less likely. IgA-associated glomerulonephritis usually does not present with this degree of proteinuria. (Choice C) Membranous nephropathy due to hepatitis B or C and syphilis can occur in the context of HIV, but hypertension and hematuria are commonly seen with membranous nephropathy. (Choice D) Minimal change disease typically presents with explosive-onset nephrotic range proteinuria, hyperlipidemia, and hypoalbuminemia. Also, minimal change disease is not seen as often in HIV patients. (Choice E) Interstitial nephritis is commonly seen in patients with HIV. While acute interstitial nephritis can be associated with heavy proteinuria, chronic interstitial nephritis usually does not present with heavy proteinuria and often has white blood cells and cellular casts on urinalysis. Educational objective: Focal segmental glomerulosclerosis (FSGS) is the most characteristic renal lesion seen in African-Americans with HIV. FSGS in HIV-infected individuals is associated with large echogenic kidneys on ultrasound, few red or white blood cells on urinalysis, heavy proteinuria, and hypoalbuminemia. Surprisingly, hypertension is not seen despite the high incidence of hypertension seen in African Americans. __________ References: Pathogenesis and treatment of HIV-associated renal diseases: lessons from clinical and animal studies, molecular pathologic correlations, and genetic investigations. (http://www.ncbi.nlm.nih.gov/pubmed/12899589) Pathologic classification of focal segmental glomerulosclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/12704572)

A 43-Year-Old African-American Man with Known HIV Is Evaluated for Edema