Renal-Main肾病-31-40

RenalMain31-40Q1A35-year-oldAfricanAmericanmancomestothephysiciancomplainingof2weeksofabdominaldistension.Hehasbeeninadrugrehabilitationprogramfor2yearsduetopriorheroinabuse.RecentviralhepatitisHIVprofileswerenegative.Histemperatureis37.1℃(98.7℉),bloodpressureis145/82mmHg,pulseis80/min,andrespirationsare14/min.Thepatientisobesewithabodymassindexof40kg/㎡.Examinationshowsperiorbitaledema:ascites,and2+pittingedemainbothlegsuptotheknees.Breathsoundsaredecreasedattherightlungbase.Twenty-four-hoururineshowsproteinexcretionof7.5g.Whichofthefollowingismostlikelytobepresentonkidneybiopsy?A.FocalsegmentalglomerulosclerosisB.lgAnephropathyC.MembranousnephropathyD.MinimalchangediseaseE.SystemicamyloidosisA1Correctanswer:AThispatient'spresentationisconsistentwithnephroticsyndrome,definedasheavyproteinuria(3.5g/24hr)withhypoalbuminemiaandedema.Otherfindingsincludehyperlipidemiaandincreasedlipidsintheurine.Causesofnephroticsyndromeinadultsincludeprimaryglomerular(eg:membranousnephropathy,focalsegmentalglomerulosclerosis[FSGS],andminimalchangedisease)andsecondaryglomerular(eg,diabetesmellitus,amyloidosis)diseases.Thispatienthasvolumeoverload(periorbitaledema,peripheraledema,andascites)likelyduetohypoalbuminemia.Hispulmonaryexaminationsuggestsalikelyrightpleuraleffusion.Becausehedoesnothaveknowndiabetesoramyloidosis,hemostlikelyhasaprimaryrenaletiology.RecentUnitedStatesregistrydataindicatethatFSGSisthemostcommoncauseofnephroticsyndromeinadults,especiallyinAfricanAmericans.FSGScanalsobeassociatedwithHIV,heroinuse,andmorbidobesity.(ChoiceB)IgAnephropathycanpresentwithnephroticsyndrome(10%),butmorecommonlypresentswithhematuriafollowinganupperrespiratoryinfection(about40%-50%ofpatients).(ChoiceC)Membranousnephropathyisthesecondleadingcauseofnephroticsyndromeintheoverallpopulation.FSGSisstatisticallymorelikelyinthispatientgiventhatheisAfricanAmericanwithobesityandheroinuse.(ChoiceD)Minimalchangediseaseismorecommonamongchildren.Inadults,itisassociatedwithuseofnonsteroidalanti-inflammatorydrugsandlymphoma(usuallyHodgkin),(ChoiceE)Amyloidosisisusuallyassociatedwithmultiplemyelomaorachronicinflammatorydisease(eg,rheumatoidarthritis,bronchiectasis).Educationalobjective:Nephroticsyndromeisdefinedasheavyproteinuria(3.5g/24hr)withhypoaibuminemiaandedema.Focalsegmentalglomerulosclerosis(FSGS)andmembranousnephropathyarethemostcommoncausesofnephroticsyndromeinadultsintheabsenceofasystemicdisease.FSGSismorecommoninAfricanAmericanpatientsandinthosewithobesity,heroinuse,andHIV.Q2A30-year-oldAfricanAmericanmancomestothephysicianbecauseofatwo-weekhistoryoffatigueandankleedema.HeisHIV-positive.Hetakesnomedications.Hedoesnotusetobacco,alcohol,ordrugs.Histemperatureis36.7°C(98°F),bloodpressureis140/86mmHgandrespirationsare16/min.Physicalexaminationshowsmiidankleedema.Laboratorystudiesshow:Urinalysisrevealed3+proteinuriabutotherwiseshowsnoabnormalities.CD4counttakenthreeweeksagowas550.Whichofthefollowingisthemostprobableformofkidneydiseaseinthispatient?A.MembranousglomerulonephritisB.MesangioproliferativeglomerulonephritisC.FocalandsegmentalglomerulosclerosisD.DiffuseproliferativeglomerulonephritisE.AcuteInterstitialnephritisA2Correctanswer:CHIVischaracterizedbyseveralformsofkidneydamage.Theclassicandmostcommononeiscollapsingfocalandsegmentalglomerulosclerosis.AnothernameforthisdiseaseisHIV-relatednephropathy.Typicalpresentationofthediseaseincludesheavyproteinuriawithrapiddevelopmentofrenalfailure.Itisinterestingthatfocalsegmentalglomerulosclerosiscanbemanifestedevenifai!themarkersofHIV(CD4count,viralload)arenormal.Foranunknownreason,thediseaseismoreprevalentamongblacksthanamongotherethnicgroups.(ChoicesA,BandD)OtherformsofHIV-relatedglomerulopathiesthatcanpresentwithnephrotic-rangeproteinuriaaremembranousglomerulonephritis,oftenseeniftheyalsohavehepatitis-Binfection,mesangioproliferativeglomerulonephritis,anddiffuseproliferativeglomerulonephritis.Theyarelesscommonthanfocalsegmentalglomerulosclerosis.(ChoiceE)InterstitialnephritiscanoccurduringHIV,buttheclinicalscenariodescribed(eg.,nephrotic-rangeproteinuria)isunusualforinterstitialnephritis.Educationalobjective:CollapsingfocalandsegmentalglomerulosclerosisisthemostcommonformofglomerulopathyassociatedwithHIV.Typicalpresentationoffocalsegmentalglomerulosclerosisincludesnephroticrangeproteinuria,azotemia,andnormalsizedkidneys.Q3A45-year-oldmancomestotheemergencydepartmentcomplainingofdyspnea,fatigue,poorappetite,andweightgainoverthepast2weeks.Hissymptomsstartedwithworseningshortnessofbreathwithexertion.Hehasbeenwakingupatnightbreathlessforthepastfewdays.Healsofindsitdifficulttoopenhiseyesinthemorningduetofacialedema.Thepatienthasnoothermedicalproblemsandtakesnomedications.Hisbloodpressureis200/120mmHgandpulseis100/min.Physicalexaminationshowsanasarcawithdistendedjugularveinswhilesittingupright.Lungauscultationshowsbibasiiarcrackles.Urinalysisshows1+protein,nonitrite,traceleukocyteesterase,50redbloodcells,redbloodcellcasts,andoccasionalneutrophils.Whichofthefollowingisthemostlikelymechanismofthi