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Minimal Change Disease and Focal Segmental Glomerulosclerosis

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Minimal Change Disease and Focal Segmental Glomerulosclerosis 4 Minimal Change Disease and Focal Segmental Glomerulosclerosis Agnes B. Fogo Introduction/Clinical Setting Minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) are both common causes of the nephrotic syndrome. Minimal change disease accounts for greater than 90% of cases of nephrotic syn- drome in children, vs. 10% to 15% of adults with nephrotic syndrome (1). Focal segmental glomerulosclerosis has been increasing in incidence in the United States in both African Americans and in Hispanics, in both adult and pediatric populations (2–4). It is now the most common cause of nephrotic syndrome in adults in the U.S. Patients with FSGS may have hypertension and hematuria. Serologic studies, including complement levels, are typically within normal limits in both MCD and FSGS. Pathologic Features Light Microscopy Minimal change disease shows normal glomeruli by light microscopy (Fig. 4.1). In FSGS, sclerosis involves some, but not all, glomeruli (focal), and the sclerosis affects a portion of, but not the entire, glomerular tuft (seg- mental) (Fig. 4.2) (1,5–7). Sclerosis is defined as increased matrix with obliteration of the capillary lumen. Uninvolved glomeruli in FSGS show no apparent lesions by light microscopy; FSGS may also entail hyalinosis, caused by insudation of plasma proteins, producing a smooth, glassy (hyaline) appearance (Fig. 4.3). Adhesions (synechiae) of the capillary tuft to Bowman’s space are a very early sclerosing lesion. Focal segmental glomerulosclerosis is diagnosed when even a single glomerulus shows segmental sclerosis. Therefore, samples must be ade- quate to detect these focal and segmental lesions. A biopsy with only 10 glomeruli has a 35% probability of missing a focal (10% involved) lesion, decreasing to 12% if 20 glomeruli are sampled (8). The juxtamedullary 40 4. Minimal Change Disease and Focal Segmental Glomerulosclerosis 41 Figure 4.1. Normal glomeruli in minimal change disease (Jones silver stain). Figure 4.2. Glomerulosclerosis in focal and segmental pattern in focal segmental glomerulosclerosis, not otherwise specified (FSGS NOS) type [periodic acid- Schiff (PAS)]. Figure 4.3. Extensive hyalinosis and sclerosis in FSGS NOS type (Jones silver stain). 42 A.B. Fogo region also should be included in the biopsy for optimal sampling, because that is where FSGS starts (5). Multiple step sections should also be exam- ined to detect the focal segmental lesions. Global glomerulosclerosis, in contrast to the segmental lesion, is not of special diagnostic significance in diagnosing FSGS. Globally sclerotic glomeruli may be normally seen at any age. In children, less than 1% global sclerosis is expected. The extent of global sclerosis increases with aging. Smith et al. (9) proffered the formula for normal percent of global sclerosis in adults of up to half the patient’s age, minus 10, for example, up to 30% by age 80. Morphologic variants of sclerosis appear to have differing prognosis (see below) (10,11). The most common type of FSGS, FSGS not otherwise specified (NOS), has no specific distinguishing features, and is character- ized by segmental sclerosis, defined as increased matrix and obliteration of capillary lumina, often with hyalinosis in the absence of underlying immune complexes or other indicators of a secondary etiology by complete immunofluorescence/electron microscopy (IF/EM) evaluation; FSGS NOS is diagnosed by exclusion of specific subtypes as follows (Fig. 4.4): Collaps- ing variant of FSGS is characterized by collapse of the capillary loops and overlying podocyte proliferation, and has a particularly ominous prognosis (Fig. 4.5) (12,13). Even just one glomerulus with collapsing lesion is suffi - cient, we propose, to classify the process as collapsing variant FSGS. In the absence of collapsing lesions, the location of lesions, either peripheral or hilar, has significance as follows: The glomerular tip lesion is defined as sclerosis only affecting the tubular pole of the glomerulus, with adhesion of the tuft to the proximal tubule outlet (Fig. 4.6). There is often associated endocapillary hypercellularity and intracapillary foam cells (14–16). The Hierarchical Classification of FSGS ? Collapsing lesion(s) Yes Collapsing variant No ? Tip lesion(s) Yes No perihilar Yes Tip variant sclerosis No No Yes ? Cellular lesion(s) Cellular variant No In > 50% of ? Hilar hyalinosis Yes Yes segmental Hilar variant ± sclerosis lesions? No No No defining lesions FSGS NOS Figure 4.4. Hierarchical classification schema for FSGS variants. 4. Minimal Change Disease and Focal Segmental Glomerulosclerosis 43 Figure 4.5. Collapse of glomerular tuft with overlying podocyte hyperplasia in collapsing type FSGS (Jones silver stain). cellular variant of FSGS is characterized by segmental proliferative podo- cyte reaction associated with early sclerosis and/or endocapillary hyper- cellularity and often intracapillary foam cells (17). It does not, per definition, involve the tubular pole. Predominantly hilar lesions, that is, more than half of sclerotic glomeruli with sclerosis with associated hyaline at the hilar pole, in the absence of collapsing lesions, have been proposed to represent a response to reduced renal mass, and may also be associated with secondary FSGS seen with arterionephrosclerosis (10,11). Vascular sclerosis may be prominent late in the course of FSGS and is proportional to glomerular sclerosis. Tubular atrophy is often accompanied Figure 4.6. Adhesion and endocapillary foam cells at proximal tubular pole in tip variant of FSGS (Jones silver stain). 44 A.B. Fogo by interstitial fi brosis, proportional to the degree of scarring in the glom- erulus. In HIV nephropathy and collapsing glomerulopathy, tubular lesions are disproportionally severe, with cystic dilation and a more prominent infiltrate (18). The presence of acute interstitial nephritis (i.e., edema, interstitial infil- trate of lymphocytes, plasma cells, and often eosinophils), and apparent MCD glomerular lesion (i.e., complete foot process effacement, no light microscopic lesions) suggest a drug-induced hypersensitivity etiology, in particular nonsteroidal antiinfl ammatory drug (NSAID)-related injury. Surrogate markers of unsampled FSGS have been sought to suspect FSGS even when sclerosed glomeruli are not detected. Abnormal glomeru- lar enlargement (see below) appears to be an early indicator of the sclerotic process preceding overt sclerosis (19). Tubulointerstitial fi brosis in a young patient without sclerosis could also indicate possible unsampled FSGS. Immunofluorescence Microscopy There are no immune complex deposits in either MCD or FSGS. In FSGS, there may be nonspecifi c entrapment of immunoglobulin M (IgM) and C3 in sclerotic areas or areas where mesangial matrix is increased. IgM stain- ing without deposits by EM does not appear to have specific diagnostic, prognostic, or etiologic significance (20). Electron Microscopy Electron microscopy shows foot process effacement, vacuolization, and microvillous transformation of epithelial cells in both MCD and FSGS. In MCD, foot process effacement is typically extensive (Fig. 4.7). Foot process Figure 4.7. Extensive foot process effacement is present in minimal change disease, and also in FSGS. No immune complexes are present (electron microscopy). 4. Minimal Change Disease and Focal Segmental Glomerulosclerosis 45 effacement is often not complete in FSGS (20). However, the extent of foot process effacement does not allow precise distinction between the two disease processes. In secondary FSGS, foot process effacement is generally less than in idiopathic forms. In HIV-associated nephropathy (HIVAN), there are reticular aggregates in endothelial cell cytoplasm. Etiology/Pathogenesis The pathogenesis of MCD appears related to abnormal cytokines, which only affect glomerular permeability and do not promote sclerogenic mech- anisms. Minimal change disease has been associated with drug-induced hypersensitivity reactions, bee stings, Hodgkin’s disease, and other venom exposure, implicating immune dysfunction as an initiating factor. Glomerular hypertrophy may be marker of FSGS. Glomerular enlarge- ment precedes overt glomerulosclerosis in FSGS (19). Patients with abnor- mal glomerular growth on initial biopsies that did not show overt sclerotic lesions subsequently developed overt glomerulosclerosis, documented in later biopsies. A cutoff of glomerular area larger than 50% more than normal for age indicated increased risk for progression. Of note, glomeruli grow until approximately age 18 years, so age-matched controls must be used in the pediatric population. Since tissue processing methods may influence the size of structures in tissue, it is imperative that each labora- tory determines normal ranges for this parameter. Recurrence of FSGS in the transplant has also shed light on its patho- genesis (21). Most recurrences occur within the first months after trans- plantation, but recurrence may be immediate. Foot process effacement is present when proteinuria recurs and precedes the development of sclerosis, typically by weeks to months. A circulating factor has been identified in patients with recurrent FSGS, which induces increased ex vivo glomerular permeability, and also a mild increase in proteinuria when injected in rats (22). Plasmapheresis induced remission in some patients with recurrent FSGS, but more often relapse occurred when plasmapheresis was stopped. Differentiation markers of podocytes, including the Wilms’ tumor WT-1 protein, podocalyxin, and synaptopodin, are retained
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