Test Your Knowledge: Nodular Glomerulosclerosis

In the May issue of the American Journal of Kidney Diseases, Kwok et al present an interesting teaching case of nephrotic syndrome with glucosuria. The teaching case reviews causes of nodular glomerulosclerosis and in particular smoking-related pathology in the kidney.

There are multiple causes of nodular glomerulosclerosis and we have developed a set of anagrams to explore these causes. Test your knowledge!

An anagram is a type of word play, a set of jumbled letters that can be rearranged to find a hidden answer (original word/phrase). For example, “main party here (1 word)”is an anagram for “hypernatremia.” Each anagram is followed by a hint meant to intellectually direct the reader towards the correct answer. The number of words that would form the final answer is indicated in parentheses next to the anagram.

1.  MINI POOL RARELY BLURS FIREFLIGHT (2 words)

A 57-year-old woman with a history of hypertension presents with a rising serum creatinine from 1.4 mg/dL (estimated glomerular filtration rate [eGFR], 39 mL/min/1.73 m2) to 2.6 mg/dL (eGFR, 19 mL/min/1.73 m2) over the last 10 months, hematuria, and proteinuria (3.7 g per 24-hour urine). Physical examination is notable for a blood pressure of 155/79 mm Hg and 1+ lower extremity edema. Urinalysis showed 3+ protein and 10-20 red blood cells per high-power field. All serologies are negative and no evidence of a monoclonal spike is present on serum or urine protein electrophoresis with immunofixation. A kidney biopsy is performed, and light microscopy reveals a membranoproliferative pattern with mesangial expansion. Immunoflouroscence microscopy shows immunoglobulin G (IgG) deposits, specially IgG4 subtype. Electron microscopy reveals 16-25 nm fibrils deposited in mesangial and capillary walls.

2. MICROCHIP GOT TO A BRAINY MOTH (2 words)

A 67-year-old man with no known kidney disease presents with worsening hypertension, hematuria, non-nephritic range proteinuria, and acute kidney injury. He was diagnosed of advanced bladder cancer 8 months ago and has been treated with gemcitabine and carboplatin. His labs reveal white blood cell count of 3200 ×103/µL, hemoglobin 7.2 g/dL, platelet count 56 ×103/µL, potassium 5.4 mEq/L, creatinine 3.4 mg/dL (eGFR, 18 mL/min/1.73 m2), blood urea nitrogen 67 mg/dL, and lactate dehydrogenase 786 U/L. Serum haptoglobin is undetectable. Kidney biopsy performed reveals nodular glomerulosclerosis and eosinophilic thrombi in blood vessels on light microscopy.

3. NUMERICAL BIOLOGY (1 word)

A 54-year-old woman presents with nephrotic syndrome and microscopic hematuria. Serologic workup reveals evidence of hepatitis C infection and depressed C3 and C4 complement levels. Kidney biopsy is performed, and light microscopy reveals a membranoproliferative pattern with nodular mesangial expansion. Immunofluorescence microscopy reveals mesangial and capillary wall deposits that stain predominantly for IgM.

4. MAYO IS SOLID (1 word)

A 78-year-old Russian man presents with worsening fatigue, nausea, diarrhea, and weight loss over the last 2 months. Labs demonstrate a creatinine of 3.9 mg/dL (eGFR, 15 mL/min/1.73 m2) and proteinuria of 16 g over 24 hours. Creatinine was 1.3 mg/dL (eGFR, 53 mL/min/1.73 m2) 6 months ago. Physical examination is notable for a blood pressure of 95/49 mm Hg, hepatomegaly, and 2+ lower extremity edema. Urinalysis showes large protein and 5 to 10 red blood cells per high-power field. All serologies are negative. A serum kappa to lambda light chain ratio is 0.05. A kidney biopsy is performed, and light microscopy reveals a nodular pattern of injury. Electron microscopy reveals 8-10 nm fibrils deposited in mesangial and capillary walls. Visualization under polarized light reveals this diagnosis.

Here’s to a fruitful learning experience!

Questions prepared by Arun Chawla, MD, Nephrology Fellow, Hofstra NSLIJ School of Medicine, and Kenar D. Jhaveri, MD, eAJKD Blog Editor

Answers can be found here.

To view the article abstract or full-text (subscription required), please visit AJKD.org.

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