A 52-year-old obese woman with a body mass index of 42 kg/m2 and long-standing hypertension is evaluated for proteinuria of 2.5 g/day. Biopsy shows glomerulomegaly with perihilar segmental sclerosis and hyalinosis. Podocyte foot processes show only mild, patchy effacement. Which feature supports secondary adaptive FSGS over primary FSGS?

• A Perihilar location of sclerosis with preserved foot processes and absence of nephrotic-range proteinuria ✓
• B Diffuse foot process effacement with rapid onset of full nephrotic syndrome
• C Tip location of the sclerotic lesion with adhesions to the tubular pole
• D Collapsing pattern with podocyte hypertrophy and microcystic tubular dilatation

Explanation

Secondary adaptive FSGS results from hyperfiltration in obesity, hypertension or reduced renal mass. Its hallmarks are glomerulomegaly, sclerosis clustered at the vascular pole (perihilar variant), only mild or segmental foot process effacement because injury is hemodynamic rather than podocyte-toxic, and subnephrotic proteinuria without the full nephrotic syndrome. Diffuse effacement and abrupt nephrotic syndrome suggest primary FSGS. The tip and collapsing variants are Columbia categories not specific to adaptive injury.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.