Lipid abnormalities in renal disease

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A 32-year-old white man developed swelling of his feet and ankles and facial swelling in the mornings. Physical examination revealed blood pressures ranging between 130—140/95—100 mm Hg and peripheral edema. Laboratory evaluation showed: BUN, 9 mg/dl; plasma creatinine, 0.9 mg/dl; plasma total protein, 3.5 g/dl; plasma albumin, 1.7 g/dl; and plasma cholesterol, 448 mg/dl. Urinalysis disclosed 4+ protein and microhematuria. A 24-hour urine collection contained 17 g of protein; creatinine clearance was 112 mllmin. Appropriate serologic tests were negative, and a diagnosis of idiopathic nephrotic syndrome was made. A renal biopsy yielded 14 glomeruli; one was globally sclerotic and 3 others had lesions of segmental sclerosis. Immunofluorescence and electron microscopy established the diagnosis of focal segmental gbmerulosclerosis. The patient was treated with sodium restriction and diuretics for his edema, and prednisone, 120 mg every other day, for longer than 3 months; the proteinuria did not abate. Proteinuria ranged from 11.7 to 15.8 g daily, plasma albumin from 1.9 to 1.5 g/dl, total protein from 3.6 to 4.5 g/dl, and total cholesterol from 575 to 700 mg/dl (Chem 20 panel results). After the corticosteroids were tapered, the patient was instructed in a 300 mg cholesterol, low-saturated-fat diet. After 2 months of this diet, his plasma lipids were accurately measured by ultracentrifugation: cholesterol, 399 mgldl; LDL cholesterol, 329 mg/dl; VLDL cholesterol, 33 mgldl; HDL cholesterol, 37 mg/dl; and total triglyceride, 378 mg/dl. The cholesterol-binding resin colestipol hydrochloride (Colestid) was prescribed for 3 months; total cholesterol decreased to 341 mgldl (LDL cholesterol, 276 rng/dl; VLDL cholesterol, 32 mgldl; HDL cholesterol, 33 mg/dl; triglyceride, 405 mg/dl). He then discontin-