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Mechanisms of Disease: focal segmental glomerulosclerosis

Nature Clinical Practice Nephrology volume 1, pages 44–54 (2005)Cite this article

Abstract

Focal segmental glomerulosclerosis (FSGS), a subtype of 'idiopathic nephrotic syndrome', is not a single disease, but a lesion that initially affects the glomerulus followed by the tubulointerstitium and renal vessels. The term 'FSGS' does not accurately encompass the various pathologic features of the glomerulus, which are not always focal, segmental or sclerotic. Particular variants of FSGS, such as collapsing glomerulopathy and the glomerular tip lesion, exemplify the nosologic uncertainty inherent in the classification of glomerular lesions. Pathologic variation notwithstanding, all pathologic processes that affect the podocyte lead to one of the histologic subtypes of FSGS. This specialized cell type has essential roles in maintaining the integrity of glomerular architecture, resisting endocapillary hydraulic pressure and hindering egress of proteins into the urinary space. Once initiated, podocyte lesions and ensuing fibrosis are usually irreversible, at least in human forms of FSGS. Remarkable progress has been made in unraveling the mechanisms of podocyte dysregulation that accompany the cellular variants of FSGS and in identifying genetic mutations affecting proteins of the slit diaphragm. Hopefully, this progress will drastically improve treatments for what is one of the most difficult therapeutic challenges to confront the nephrologist.

Key Points

  • The diverse histologic subtypes of focal segmental glomerulosclerosis (FSGS) are unified by the central pathophysiological role of the podocyte

  • Nuclear dysregulation, derangement of the cell cycle and morphologic changes are features of podocytes in FSGS

  • Podocyte dysregulation perturbs glomerular architecture leading to the primary clinical feature of FSGS—proteinuria

  • Evidence supports a central role for an elusive 'glomerular permeability factor' in pathogenesis of FSGS

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Figure 1: Artist's view of the arrangement of the podocyte foot process and slit diaphragm proteins.
Figure 2: Cellular variant of focal segmental glomerulosclerosis.
Figure 3: Other variants of focal segmental glomerulosclerosis.
Figure 4: Podocyte transdifferentiation.
Figure 5: Podocyte proliferation in cellular variants of focal segmental glomerulosclerosis.

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Acknowledgements

I am greatly indebted to Jean Bariéty MD, Professor Emeritus, Paris-Descartes University, for kindly providing the histopathologic images and critically reviewing the text.

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  1. a Senior Nephrologist in the Department of Nephrology of Hospital Georges Pompidou, Université Paris-Descartes, Faculté de Médecine, Paris, France

    Alain Meyrier

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Correspondence to Alain Meyrier.

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Meyrier, A. Mechanisms of Disease: focal segmental glomerulosclerosis. Nat Rev Nephrol 1, 44–54 (2005). https://doi.org/10.1038/ncpneph0025

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