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This biopsy was performed on a 26 year old muscular male with history of persistent subnephrotic proteinuria (UPCR = 2.3 g/g) and preserved renal function. Serum albumin is maintained at 4.2 gm/dl with the remaining serologic workup negative. BMI is 38.2 kg/m2. Of note, the patient has a history of premature birth and has a twin brother with similar clinical presentation. The biopsy shows marked glomerular hypertrophy (Fig 1 and 2) with no evidence of segmental glomerulosclerosis, tubulointerstitial scarring, immune complex deposition or significant foot process effacement. Glomerular hypertrophy (glomerulomegaly) is a form of adaptive structural-functional response which occurs as...