细胞型局灶性节段性肾小球硬化还是塌陷性肾小球病？有明确的诊断了吗？

可见23个肾小球，6个肾小球球性硬化，1个节段性硬化。

其余肾小球局灶节段性毛细血管襻内细胞增殖，导致毛细血管腔塌陷、闭塞，其中6个肾小球毛细血管腔完全闭塞，足细胞增生、肥大和空泡变性，有的聚集形成假新月体样结构。

肾小管上皮细胞空泡及颗粒变性，部分管腔扩张，可见较多蛋白管型，多灶状萎缩，肾间质多灶状炎症细胞浸润伴纤维化，小动脉管壁无明显病变。

在诊断上，因为看到毛细血管襻有内皮细胞的增生，所以没有诊断为塌陷性肾小球病，诊断为细胞型FSGS，最近临床医生反馈的信息是病人治疗效果很差，让我们再复查一下切片，所以将这个病例发上来，请大家会诊。

我们的电镜是送到外单位做的，诊断的结果是系膜增生性肾小球肾炎，因为没有提供给照片，所以没法传给大家，如果QU老师觉得有必要，我可以让他们将电镜的切片提供给我们。

系膜增生性肾小球肾炎 (mesangial proliferative GN)is a confusing entity. It includes so many renal diseases. I have not used this term in my diangosis.

Your initial diangosis (细胞型FSGS) was a good choice.  细胞型FSGS is difficult to be distinquished from collapsing FSGS or glomerulopathy. In the textbook, presence or absence of endocapillary hypercellularity has been considered as morphological feature to separate these two entities. In daily practce, that feature is not very helpful. In some of my report, the diagnosis was worded as "cellular variant of FSGS/collapsing FSGS".  Cellular variant of FSGS is supposed to be responsive to the therapy and collapsing FSGS is unresponsive to therapy and progress to renal failure rapidly.

In the above case, if podocytes show extensive effacement (described by 外单位 EM report?), it is enough to diagnose cellular variant of FSGS. The morphologic features (at light level) are also consistent with cellular variant of FSGS. But the patient's response reminds me of collapsing FSGS. Do you know your patient's HIV status and medication history?

 ！

 ！