A 34-year-old African American man with untreated HIV infection and CD4 count of 180 cells/mm3 presents with proteinuria of 7 g/day, rapidly falling creatinine and blood pressure of 150/95 mm Hg. Renal biopsy shows collapse of glomerular tufts with overlying podocyte hyperplasia, marked tubular microcystic dilatation containing proteinaceous casts, and tubuloreticular inclusions in endothelial cells on electron microscopy. What is the diagnosis?

• A Classic idiopathic focal segmental glomerulosclerosis, perihilar variant
• B Collapsing glomerulopathy (HIV-associated nephropathy) ✓
• C Membranoproliferative glomerulonephritis
• D Thrombotic microangiopathy from antiretroviral therapy

Explanation

HIV-associated nephropathy is a collapsing variant of FSGS seen predominantly in persons of African ancestry carrying two APOL1 risk alleles. Its hallmarks are tuft collapse with podocyte hyperplasia and crowding, striking microcystic tubular dilatation filled with casts, and tubuloreticular inclusions reflecting high interferon levels. Classic FSGS variants lack tuft collapse and microcystic change, MPGN would show hypercellularity with deposits, and the clinical picture with these biopsy features is diagnostic of HIVAN rather than drug-induced TMA.

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.