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A renal biopsy was performed on this 52-year-old male with a history of hypertension and heavy tobacco use, who is being worked up for nephrotic range proteinuria and increased creatinine. The glomeruli (Fig 1 and 2) show nodular mesangial matrix expansion without definitive proliferation, necrosis or crescents. Focal areas of segmental glomerulosclerosis are present. There is no evidence of immune complex or monoclonal immunoglobulin deposition by immunofluorescence or electron microscopy. Of note, electron microscopy does show global thickening of glomerular basement membranes (not shown). While non-specific, the most common cause of nodular glomerulosclerosis in the United States is diabetes mellitus/glucose...