Nephrotic syndrome, Focal segmental glomerulosclerosis

Swollen 3

Step 1: View clinicals

A 28-year-old African-American man presents with facial swelling, swelling of both legs, and frothy urine for five days. The facial swelling was most prominent around the eyes, being worst at morning and slowly resolving through the day. There is no history of fever, dysuria, urgency or hematuria, and his urine output is normal. No other symptoms are present. His medical and surgical histories are unremarkable. In particular, there is no history of obstructive sleep apnea. He is not on any medications, including herbal supplements or over-the-counter drugs. He does not have a history of chemical exposure, radiation, or infection. He has never smoked, drinks socially in only small quantities and denies using recreational drugs. His family history is unremarkable. A complete blood count, renal profile, liver profile, random plasma glucose, HbA1c, lipid profile, and urinalysis are performed. These are only significant for serum albumin of 1.9 g/dL (3.5-5.5), triglycerides of 450 mg/dL (<150), 3+ proteinuria, hyaline casts on urine microscopy, and a urinary protein:creatinine ratio of 3.2 mg/mg (<0.11).


Step 2: Order all relevant investigations

Renal ultrasound

The renal ultrasound scan shows no abnormalities.

Autoimmune screen

c-ANCA: negative p-ANCA: negative Anti-GBM antibodies: negative ANA, C3, C4: within normal ranges

Renal biopsy

The biopsy specimen shows segmental solidification of the peripheral region of the glomerular tuft and tubular pole, suggestive of focal segmental glomerulosclerosis.

Viral screen

The viral screen is negative for HIV, parvovirus B19, cytomegalovirus, Epstein-Barr virus, hepatitis B, and hepatitis C.


Step 3: Select appropriate management

Diuretics
Thromboprophylaxis
Glucocorticoids
Immunosuppressants


Score: ★★☆