Focal segmental glomerulosclerosis
| Focal segmental glomerulosclerosis | |
|---|---|
| Classification and external resources | |
 Light micrograph of focal segmental glomerulosclerosis, hilar variant. Kidney biopsy. PAS stain. | |
| ICD-10 | N00-N08 (with .1 suffix) |
| ICD-9 | 581.1 |
| OMIM | 603278 603965 607832 612551 613237 600995 |
| MedlinePlus | 000478 |
| eMedicine | med/2944 |
| MeSH | D005923 |
Focal segmental glomerulosclerosis (FSGS) is a cause of nephrotic syndrome in children and adolescents, as well as an important cause of kidney failure in adults.[1] It is also known as "focal glomerular sclerosis" or "focal nodular glomerulosclerosis."[2] It accounts for about a sixth of the cases of nephrotic syndrome.[3] (Minimal change disease (MCD) is by far the most common cause of nephrotic syndrome in children: MCD and primary FSGS may have a similar cause.[1])
Appearance
The individual components of the name refer to the appearance of the kidney tissue on biopsy: focal—only some of the glomeruli are involved (as opposed to diffuse), segmental—only part of each glomerulus is involved (as opposed to global),[4] glomerulosclerosis—refers to scarring of the glomerulus (a part of the nephron (the functional unit of the kidney)). The glomerulosclerosis is usually indicated by heavy PAS staining and findings of IgM and C3 in sclerotic segment.[5]
Classification
Depending on the cause it is broadly classified as:
- Primary, when no underlying cause is found; usually presents as nephrotic syndrome
- Secondary, when an underlying cause is identified; usually presents with kidney failure and proteinuria. This is actually a heterogeneous group including numerous causes such as
- Infections such as HIV (known as HIV-Associated Nephropathy)
- Toxins and drugs such as heroin and pamidronate
- Familial forms
- Secondary to nephron loss and hyperfiltration, such as with chronic pyelonephritis and reflux, morbid obesity, diabetes mellitus
There are many other classification schemes also.
Pathologic variants
Five mutually exclusive variants of focal segmental glomerulosclerosis may be distinguished by the pathologic findings seen on renal biopsy:[6]
- Collapsing variant
- Glomerular tip lesion variant
- Cellular variant
- Perihilar variant
- Not otherwise specified (NOS) variant.
Recognition of these variants may have prognostic value in individuals with primary focal segmental glomerulosclerosis (i.e. where no underlying cause is identified). The collapsing variant is associated with higher rate of progression to end-stage renal disease, whereas glomerular tip lesion variant has low rate of progression to end-stage renal disease in most patients.[6] Cellular variant shows similar clinical presentation to collapsing and glomerular tip variant but has intermediate outcomes between these two variants. However, because collapsing and glomerular tip variant show overlapping pathologic features with cellular variant, this intermediate difference in clinical outcomes may reflect sampling bias in cases of cellular focal segmental glomerulosclerosis (i.e. unsampled collapsing variant or glomerular tip variant). The prognostic significance of perihilar and NOS variants has not yet been determined. The NOS variant is the most common subtype.[6]
Causes
There are currently several known genetic causes of the hereditary forms of FSGS.
| Gene | OMIM | Description |
|---|---|---|
| FSGS1: ACTN4 | 603278 | The first gene involved with this disorder is ACTN4, which encodes alpha-actinin 4. This protein crosslinks bundles of actin filaments and is present in the podocyte. Mutations in this protein associated with FSGS result in increased affinity for actin binding, formation of intracellular aggregates, and decreased protein half-life. While it is unclear how these effects might lead to FSGS there are a number of theories. Firstly, protein aggregation may have a toxic effect on the podocyte. Secondly, decreased protein half-life or increased affinity for actin binding may alter actin polymerization and thereby affect the podocytes cytoskeletal architecture.[7] |
| FSGS2: TRPC6 | 603965 | A second gene associated with FSGS is TRPC6, which encodes a member of the canonical family of TRP channels. This family of ion channels conduct cations in a largely non-selective manner. As with ACTN4, TRPC6 is expressed in podocytes. While TRP channels can be activated through a variety of methods, TRPC6 is known to be activated by phospholipase C stimulation. There are at least 6 mutations in this channel, located throughout the channel. At least one of these mutations, P112Q, leads to increased intracellular calcium influx. It is unclear how this might lead to FSGS, though it has been proposed that it may result in alteration of podocyte dynamics or podocytopenia.[7] |
| FSGS3: CD2AP | 607832 | Another gene that may be involved in hereditary forms of FSGS is the gene known as CD2AP (CD2 associated protein) or CMS (Cas binding protein with multiple SH3 domains). The protein expressed by this gene is expressed in podocytes where it interacts with fyn and synaptopodin. There is a report that a splicing mutation in this gene was found in two patients with HIV associated FSGS and this led to altered protein translation. This has been theorized to result in altered actin binding and, thus, alteration of the cytoskeletal podocyte architecture.[7] |
| FSGS4: APOL1 | 612551 | In people of African descent, two common variants in APOL1 have been associated with FSGS. It is believed that these variants arose as a defensive mechanism against Trypanosoma brucei rhodesiense or some other sub-Saharan parasite despite conferring high susceptibility to FSGS when inherited from both parents.[8] |
| FSGS5: INF2 | 613237 | Another gene associated with FSGS is INF2, which encodes a member of the formin family of actin-regulating proteins. The observation that alterations in this podocyte-expressed formin cause FSGS emphasizes the importance of fine regulation of actin polymerization in podocyte function.[9] |
| SRN1: NPHS2 | 600995 | Mutations in the NPHS2 gene, which codes for the protein called podocin,[10] can cause focal segmental glomerulosclerosis.[11] This is a recessive form of FSGS.[12] An affected individual has two mutant copies of the NPHS2 gene, in contrast to ACTN4 and TRPC6 mediated forms of disease, which are dominant and require only one mutant copy of the gene. NPHS2-mediated FSGS is resistant to treatment with steroids. |
Diagnosis
Symptoms and signs
In children and some adults, FSGS presents as a nephrotic syndrome, which is characterized by edema (associated with weight gain), hypoalbuminemia (low serum albumin, a protein in the blood), hyperlipidemia and hypertension (high blood pressure). In adults it may also present as kidney failure and proteinuria, without a full-blown nephrotic syndrome. Some researchers found SuPAR as cause of FSGS.
Tests
- Urinalysis
- Blood tests — cholesterol
- Kidney biopsy
Differential diagnosis
- Minimal change disease, especially in children
- Several others
Treatment
- Salt restriction and diuretics, such as furosemide, for edema
- Antihypertensives (especially ACEIs) — if the blood pressure is too high
- treat present hyperlipidemia (e.g. statins, fibrates; although fibrates are contraindicated in renal failure)
- Aldosterone antagonist to decrease proteinuria and thus offer a degree of reno-protection
- Angiotensin II receptor antagonist
- Corticosteroids, such as prednisone — based on the clinical judgment of physician (no broad consensus/guideline)[citation needed]
- Cytotoxics, such as cyclophosphamide may be used to induce remission in patients presenting with FSGS refractory to corticosteroids, or in patients who do not tolerate steroids.
- Plasmapheresis — blood cleansing using a machine to remove the patient's blood plasma and replacing it with donor plasma.
- Vitamin E
- Fish oil
- Immunosuppressive drugs
- None — sometimes none of the above works and the patient will require dialysis with possibly later transplantation of a new kidney.[citation needed]
Notable patients
Former NBA basketball players Sean Elliott and Alonzo Mourning have both survived bouts with FSGS. Mourning is an Ambassador to The NephCure Foundation. Pro bodybuilder Flex Wheeler was diagnosed with FSGS and had a kidney transplant.
See also
References
- ↑ 1.0 1.1 Kumar V, Fausto N, Abbas A, ed. (2003). Robbins & Cotran Pathologic Basis of Disease (7th ed.). Saunders. pp. 982–3. ISBN 978-0-7216-0187-8.
- ↑ "focal segmental glomerulosclerosis" at Dorland's Medical Dictionary
- ↑ "Renal Pathology". Retrieved 2008-11-25.
- ↑ "Focal_segmental_glomerulosclerosis of the Kidney". Retrieved 2008-11-25.
- ↑ "Focal_segmental_glomerulosclerosis of the Kidney". Retrieved 2009-11-20.
- ↑ 6.0 6.1 6.2 Thomas DB, Franceschini N, Hogan SL, et al. (2006). "Clinical and pathologic characteristics of focal segmental glomerulosclerosis pathologic variants". Kidney Int. 69 (5): 920–6. doi:10.1038/sj.ki.5000160. PMID 16518352.
- ↑ 7.0 7.1 7.2 Mukerji N, Damodaran TV, Winn MP (2007). "TRPC6 and FSGS: The latest TRP channelopathy". Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease 1772 (8): 859–68. doi:10.1016/j.bbadis.2007.03.005. PMID 17459670.
- ↑ Genovese G, Friedman DJ, Ross MD, Lecordier L, Uzureau P, Freedman BI, Bowden DW, Langefeld CD, Oleksyk TK, Uscinski Knob AL, Bernhardy AJ, Hicks PJ, Nelson GW, Vanhollebeke B, Winkler CA, Kopp JB, Pays E, Pollak MR. (Jul 2010). "Association of Trypanolytic ApoL1 Variants with Kidney Disease in African-Americans". Science 329 (5993): 841–5. doi:10.1126/science.1193032. PMC 2980843. PMID 20647424.
- ↑ Brown EJ, Schlöndorff JS, Becker DJ, Tsukaguchi H, Uscinski AL, Higgs HN, Henderson JM, Pollak MR. (Jan 2010). "Mutations in the formin protein INF2 cause focal segmental glomerulosclerosis". Nature Genetics 42 (1): 72–6. doi:10.1038/ng.505. PMC 2980844. PMID 20023659.
- ↑ Tsukaguchi H, Sudhakar A, Le TC, et al. (December 2002). "NPHS2 mutations in late-onset focal segmental glomerulosclerosis: R229Q is a common disease-associated allele". J. Clin. Invest. 110 (11): 1659–66. doi:10.1172/JCI16242. PMC 151634. PMID 12464671.
- ↑ Franceschini N, North KE, Kopp JB, McKenzie L, Winkler C (February 2006). "NPHS2 gene, nephrotic syndrome and focal segmental glomerulosclerosis: a HuGE review". Genet. Med. 8 (2): 63–75. doi:10.1097/01.gim.0000200947.09626.1c. PMID 16481888.
- ↑ Boute N, Gribouval O, Roselli S, Benessy F, Lee H, Fuchshuber A, Dahan K, Gubler M-C, Niaudet P, Antignac C (May 2000). "NPHS2, encoding the glomerular protein podocin, is mutated in autosomal recessive steroid-resistant nephrotic syndrome". Nature Genetics 24 (4): 349–354. doi:10.1038/74166. PMID 10742096.
External links
- Wei C, El Hindi S, Li J, Fornoni A, Goes N, Sageshima J, Maiguel D, Karumanchi SA, Yap HK, Saleem M, Zhang Q, Nikolic B, Chaudhuri A, Daftarian P, Salido E, Torres A, Salifu M, Sarwal MM, Schaefer F, Morath C, Schwenger V, Zeier M, Gupta V, Roth D, Rastaldi MP, Burke G, Ruiz P, Reiser J (July 2011). "Circulating urokinase receptor as a cause of focal segmental glomerulosclerosis". Nat Med 17 (8): 952–960. doi:10.1038/nm.2411. PMID 21804539.
- NephCure Foundation Only organization solely committed to support research seeking the cause of Nephrotic Syndrome and FSGS, improve treatment and find the cure.
- Kidcomm An online resource for parents dealing with childhood kidney diseases (FSGS, Nephrotic Syndrome and others)
- FSGS Research A team of kidney doctors and scientists from Brigham and Women's Hospital / Harvard Medical School working to learn more about the cause of FSGS and Nephrotic Syndrome in children and adults, with an emphasis on the genetic basis of these diseases.
- A general overview of Renal Pathology
- Tahzib M, Frank R, Gauthier B, Valderrama E, Trachtman H (October 1999). "Vitamin E treatment of focal segmental glomerulosclerosis: results of an open-label study". Pediatr. Nephrol. 13 (8): 649–52. doi:10.1007/s004670050674. PMID 10502120.
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