Figure 724

These two patients illustrate typical presenting features of HIV-associated glomerulosclerosis, ie, proteinuria, usually in the nephrotic range; normal-sized or large echogenic kidney; and renal insufficiency rapidly progressing to endstage renal disease (ESRD). The onset of the nephropathy is often abrupt, with uremia and massive nonselective proteinuria (sometimes in excess of 20 g/24 h). These fulminant lesions may present as acute renal failure in patients who were well only a few weeks or months before hospitalization. In other patients, minimal proteinuria and azotemia at presentation increase insidiously over a period of several months until a nephrotic syndrome becomes evident, with rapid evolution thereafter to uremia and ESRD. Hypertension and peripheral edema may be absent even in the context of advanced renal insufficiency or severe nephrotic syndrome. The status of the patient's HIV infection rather than the presence of renal disease per se has the greatest impact on survival.

Collapsed glomerular capillaries Visceral glomerular epitheliosis Microcystic tubules with variegated casts Focal tubular simplification Interstitial lymphocytic infiltration Endothelial reticular inclusions

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