BRCU 2026: Test Your Knowledge
A 40-year-old man presents to you for further workup after proteinuria was found on an insurance physical exam. His past medical history is significant for obesity and hypertension, which he says is controlled with diet. He has no symptoms and takes no medications. His BP is 146/90 mm Hg. No edema is present.
Laboratory test results are as follows:
Na 138 mEq/L
K 4.1 mEq/L
Cl 104 mEq/L
HCO3 24 mEq/L
BUN 12 mg/dL
Cr 1.2 mg/dL
Glucose 80 mg/dL
Albumin 4.2 g/dL
UA indicates 3+ protein, no blood, no RBCs. The urine albumin-to-creatinine ratio is 3.2 g/g; the urine protein-to-creatinine ratio is 4.8 g/g.
Secondary serologic workup for glomerular disease, including glycated Hb (HbA1c), ANA, double-stranded DNA, complements, PLA2R, HIV, hepatitis serology, and serum immunofixation, shows all are normal or negative.
The patient's kidney biopsy reveals focal and segmental glomerulosclerosis; 4 of 16 glomeruli have segmental scars, and 1 has global sclerosis. There is 20% interstitial fibrosis and tubular atrophy. Immunofluorescence microscopy is negative. EM shows one viable glomerulus with 25% foot process effacement.
Which is the next best step? You:
- Begin prednisone 60 mg PO daily
- Due to his obesity, begin steroid-sparing therapy with calcineurin inhibitor
- Due to his obesity, begin steroid-sparing therapy with rituximab
- Begin an angiotensin receptor blocker; immunosuppression is not indicated
Reference:
- Kidney Disease: Improving Global Outcomes (KDIGO) Glomerular Diseases Work Group. "KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases." Kidney International 100, no. 4S (2021): S1–S276. doi: 10.1016/j.kint.2021.05.021
- Sethi S, Glassock RJ, Fervenza FC. "Focal Segmental Glomerulosclerosis: Towards a Better Understanding for the Practicing Nephrologist." Nephrology Dialysis Transplantation 30, no. 3 (2015): 375–384. doi: 10.1093/ndt/gfu035
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Board Review Course & Update (BRCU) is a comprehensive, three-day, in-person course focused on key nephrology concepts that prepare you for the ABIM nephrology certification and recertification exams, as well as the Longitudinal Knowledge Assessment (LKA). Join colleagues in Chicago, IL, to face your boards with confidence.