In addition to starting an ACE inhibitor, weight loss is indicated for this patient with likely secondary focal segmental glomerulosclerosis (FSGS). This patient with obesity, hypertension, and nephrotic-range proteinuria (with normal serum albumin) has FSGS on kidney biopsy. FSGS may be primary (idiopathic) or secondary, and the appropriate therapeutic approach is based on determining the likely cause of the disorder. Primary FSGS involves glomerular injury due to an unclear insult; features suggesting primary FSGS include a low serum albumin level and extensive foot process effacement on kidney biopsy. Patients usually present with hypertension, hypoalbuminemia, and some degree of kidney failure in addition to nephrotic-range proteinuria. Some patients with primary FSGS respond well to immunosuppressive therapy, and this is typically offered to patients with this diagnosis. Secondary FSGS is believed to result from an adaptive response to glomerular hypertrophy or hyperfiltration associated with a number of conditions (including obesity) in which the glomerular filtration rate may be markedly increased; glomeruli on biopsy are often enlarged, reflecting hyperfiltration with only mild foot process effacement. These patients have minimal edema and rarely have the full spectrum of the nephrotic syndrome. In obese patients with likely secondary FSGS, weight loss is sometimes associated with a drop in proteinuria, as is the use of ACE inhibitors or angiotensin receptor blockers, and is the preferred initial therapy.

Immunosuppressive therapy with glucocorticoids or other agents such as the calcineurin inhibitor tacrolimus is not indicated in secondary FSGS.

FSGS is not typically associated with syphilis, and testing for this entity using a rapid plasma reagin test is not indicated.