Figure 212

Histologic variations of focal segmental glomerulosclerosis (FSGS). Two important variants of FSGS exist. In contrast to the histologic appearance of the involved glomeruli, with the sclerotic segment in any location in the glomerulus, the glomerular tip lesion (A) is characterized by segmental sclerosis at an early stage of evolution, at the tubular pole (tip) of all affected glomeruli (arrow). Capillaries contain monocytes with abundant cytoplasmic lipids (foam cells), and the overlying visceral epithelial cells are enlarged and adherent to cells of the most proximal portion of the proximal tubule. Some investigators have described a more favorable response to steroids and a more benign clinical course.

The other variant, known as collapsing glomerulopathy, most likely represents a virulent form of FSGS. In this form of FSGS, most visceral epithelial cells are enlarged and coarsely vacuolated and most capillary walls are wrinkled or collapsed (B). These features indicate a severe lesion, with a corresponding rapidly progressing clinical course of the disease. Integral and concomitant acute abnormalities of tubular epithelia and interstitial edema occur.

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