Abstract
The pathogenesis of glomerular hypertension-mediated FSGS and its histological variations in humans remains unknown. A 47-year-old man developed nephrotic syndrome, renal dysfunction, and malignant hypertension 2 years after donating a kidney to his son. The donor’s remnant kidney developed renal mass at an upper pole which was fed by an aberrant artery that branched from the root of the renal artery. Furthermore, the main non-aberrant renal artery demonstrated severe stenosis that caused renovascular hypertension, resulting in malignant hypertension. Upon radiological examinations, a tumorous mass was detected. Because of progressive renal dysfunction, nephrectomy was performed. The kidney revealed a diffuse distribution of complex FSGS lesions, i.e., a random combination of cellular/collapsing FSGS and glomerular thrombotic microangiopathy, confined to the renal mass, whereas such lesions were absent in the non-mass portion. This indicated that severe glomerular hypertension alone caused FSGS with TMA features. Heterogeneous FSGS lesions let us surmise that glomerular hypertension promoted simultaneous damages in endothelial cells and podocytes, which synergistically progressed to glomerulosclerosis. This unique case uncovers causal relationships between unusual glomerular hypertension and severe forms of FSGS that was possibly caused by the disruption of homeostasis sustained by podocytes and endothelial cells.
Similar content being viewed by others
References
D’Agati VD, Kaskel FJ, Falk RJ. Focal segmental glomerulosclerosis. N Engl J Med. 2011;365(25):2398–411.
Rennke HG, Klein PS. Pathogenesis and significance of nonprimary focal and segmental glomerulosclerosis. Am J Kidney Dis. 1989;13(6):443–56.
Anderson S, Meyer TW, Rennke HG, Brenner BM. Control of glomerular hypertension limits glomerular injury in rats with reduced renal mass. J Clin Invest. 1985;76(2):612–9.
Rana K, Isbel N, Buzza M, Dagher H, Henning P, Kainer G, Savige J. Clinical, histopathologic, and genetic studies in nine families with focal segmental glomerulosclerosis. Am J Kidney Dis. 2003;41(6):1170–8.
D’Agati VD, Fogo AB, Bruijn JA, Jennette JC. Pathologic classification of focal segmental glomerulosclerosis: a working proposal. Am J Kidney Dis. 2004;43(2):368–82.
Kadiri S, Thomas JO. Focal segmental glomerulosclerosis in malignant hypertension. S Afr Med J. 2002;92(4):303–5.
Fujii S, Kasahara H, Oguchi H. A case of renovascular hypertension with nephrotic syndrome, accompanied by focal segmental glomerulosclerosis-like lesion in the contralateral kidney. Nihon Jinzo Gakkai Shi. 1991;33(10):1017–24 (Japanese).
Fukuda K, Shimizu A, Kaneko T, Masuda Y, Yasuda F, Fukui M, Higo S, Hirama A, Mii A, Tsuruoka S, Ohashi R, Iino Y, Fukuda Y, Katayama Y. A case of secondary focal segmental glomerulosclerosis associated with malignant hypertension. CEN Case Rep. 2013;2:68–75.
Bohle A, Wehrmann M, Greschniok A, Junghans R. Renal morphology in essential hypertension: analysis of 1177 unselected cases. Kidney Int Suppl. 1998;67:S205–6.
Harvey JM, Howie AJ, Lee SJ, Newbold KM, Adu D, Michael J, Beevers DG. Renal biopsy findings in hypertensive patients with proteinuria. Lancet. 1992;340:1435–6.
Bohle A, Ratschek M. The compensated and the decompensated form of benign nephrosclerosis. Pathol Res Pract. 1982;174(4):357–67.
D’Agati VD. Pathobiology of focal segmental glomerulosclerosis: new developments. Curr Opin Nephrol Hypertens. 2012;21:243–50.
Alkhunaizi AM, Chapman A. Renal artery stenosis and unilateral focal and segmental glomerulosclerosis. Am J Kidney Dis. 1997;29(6):936–41.
Bhowmik D, Dash SC, Jain D, Agarwal SK, Tiwari SC, Dinda AK. Renal artery stenosis and focal segmental glomerulosclerosis in the contralateral kidney. Nephrol Dial Transplant. 1998;13(6):1562–4.
Alchi B, Shirasaki A, Narita I, Nishi S, Ueno M, Saeki T, Miyamura S, Gejyo F. Renovascular hypertension: a unique cause of unilateral focal segmental glomerulosclerosis. Hypertens Res. 2006;29(3):203–7.
Stokes MB, Markowitz GS, D’Agati VD. Cellular focal segmental glomerulosclerosis: clinical and pathologic features. Kidney Int. 2006;70(10):1783–92.
Nagata M. Podocyte injury and its consequences. Kidney Int. 2016; Published online: March 19.
Dworkin LD, Hostetter TH, Rennke HG, Brenner BM. Hemodynamic basis for glomerular injury in rats with desoxycorticosterone-salt hypertension. J Clin Invest. 1984;73(5):1448–61.
Kretzler M, Koeppen-Hagemann I, Kriz W. Podocyte damage is a critical step in the development of glomerulosclerosis in the uninephrectomised- desoxycorticosterone hypertensive rat. Virchows Arch. 1994;425(2):181–93.
Kriz W, Hosser H, Hähnel B, Simons JL, Provoost AP. Development of vascular pole-associated glomerulosclerosis in the Fawn-hooded rat. J Am Soc Nephrol. 1998;9(3):381–96.
Eremina V, Jefferson JA, Kowalewska J, Hochster H, Haas M, Weisstuch J, Richardson C, Kopp JB, Kabir MG, Backx PH, Gerber HP, Ferrara N, Barisoni L, Alpers CE, Quaggin SE. VEGF inhibition and renal thrombotic microangiopathy. N Engl J Med. 2008;358(11):1129–36.
Ueno T, Kobayashi N, Nakayama M, Takashima Y, Ohse T, Pastan I, Pippin JW, Shankland SJ, Uesugi N, Matsusaka T, Nagata M. Aberrant Notch1-dependent effects on glomerular parietal epithelial cells promotes collapsing focal segmental glomerulosclerosis with progressive podocyte loss. Kidney Int. 2013;83(6):1065–75.
Kobayashi N, Ueno T, Ohashi K, Yamashita H, Takahashi Y, Sakamoto K, Manabe S, Hara S, Takashima Y, Dan T, Pastan I, Miyata T, Kurihara H, Matsusaka T, Reiser J, Nagata M. Podocyte injury-driven intracapillary plasminogen activator inhibitor type 1 accelerates podocyte loss via uPAR-mediated β1-integrin endocytosis. Am J Physiol Renal Physiol. 2015;308(6):F614–26.
Hara S, Kobayashi N, Sakamoto K, Ueno T, Manabe S, Takashima Y, Hamada J, Pastan I, Fukamizu A, Matsusaka T, Nagata M. Podocyte injury-driven lipid peroxidation accelerates the infiltration of glomerular foam cells in focal segmental glomerulosclerosis. Am J Pathol. 2015;185(8):2118–31.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no relevant financial interests.
Human and animal right
This article is principally based on the observation and does not contain any studies with human participants performed by any of the authors.
About this article
Cite this article
Nagata, M., Yamaguchi, Y., Toki, D. et al. Complex glomerular pathology of thrombotic microangiopathy and focal segmental glomerulosclerosis forms tumor-like mass in a renal transplant donor with severe renovascular hypertension. CEN Case Rep 6, 12–17 (2017). https://doi.org/10.1007/s13730-016-0235-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13730-016-0235-0