Idiopathic Nodular Glomerulosclerosis in a New Uncontrolled Hypertensive and Passive Smoker: A Case Report

Introduction: Idiopathic nodular glomerulosclerosis (ING) is a rare disease characterized by mesangial expansion with increased nodularity in absence of diabetes or other specific diseases. Despite its unknown pathogenesis, the presence of longstanding hypertension (HTN) and active smoking are associated with this disease leading to a new term “smoking-modified HTN-associated nodular glomerulosclerosis (SHaNGS)”. Herein we report a case of ING in a passive smoker with uncontrolled HTN. Case Description: A 60-year-old female with history of polyneuropathy, monoclonal gammopathy of undetermined significance (MGUS), hypothyroidism, onychomycosis (POEMS syndrome), and HTN was referred due to increased creatinine level (1.4 mg/dl). She denied active smoking but reported long-standing exposure to cigarette smoking being surrounded by heavy smoker family members and then working as a bartender. Further workups showed hematuria (50 RBC/high power field), proteinuria (urine-protein-creatinine ratio: 2.4 g/g, increased to 2.9 g/g) with normal renal ultrasound (Table 1). Kidney biopsy results showed evidence of diffuse and focal nodular mesangial expansion without hypercellularity, negative staining for amyloid, fibrillary glomerulonephritis and immunoglobulins (both direct and pronase digested immunofluorescence), finally diagnosed as ING (Figure 1 A&B). Discussion: This case highlights a rare case of ING secondary to heavy passive smoking and uncontrolled HTN.