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The Renal Biopsy Demystified
Tom McCulloch
Consultant Histopathologist, NUH
EMEESY
14th October 2016
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How this Presentation Works
• Clinical context
• Modalities used
• Normal features
• Primer on glomerular disease patterns
• Examples of glomerular disease
• Assessment of biopsy adequacy
• Assessment of disease severity (grade)
• Assessment of disease chronicity (stage)
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Considerations
• Clinical – Acute renal failure
– Chronic renal failure
– Nephrotic syndrome
– Nephritic syndrome
– Haematuria/proteinuria
– Microscopic haematuria
• Pre renal
• Post renal
• Renal – Vascular
– Tubulointerstitial
– Glomerular • Primary
• Immune complex
• Non immune complex
• Other
– Systemic
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Normal Histology
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Techniques Used
• Light microscopy
• Immunofluorescence
• Electron Microscopy
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Haematoxylin and Eosin Stain
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PAS
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Normal
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Diabetes with Kimmelstiel Wilson nodules and arteriolar
hyalinosis
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HIV associated nephropthy
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Cryoglobulinaemia
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Methanemine Silver
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Normal
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Memebranoproliferative glomerulonephritis
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Post infectious glomerulonephritis
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Masson Trichrome - Fibrosis
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Masson Trichrome – Fibrinoid
Necrosis
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Elastin van Gieson
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Congo Red - Amyloid
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Immunofluorescence
• Immunoglobulin
– IgG, IgM, IgA,
• Complement
– C3, C4, C1q
• Light Chain
– Kappa, lambda
• Collagen type IV
subunits (Alport’s)
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Electron Microscopy
• Deposits
– Immune complex
• Podocyte morphology
– Foot process effacement
• Glomerular basement
membrane morphology
– Alport’s etc
• Organised deposits
• Amyloid etc
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Capillary lumen
Urinary space
Glomerular
basement
membrane
Podocyte foot
processes
Electron microscopy
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Patterns of Glomerular Disease
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Mesangiopathic Membranous
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Segmental
sclerosis
Membranoproliferative
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Diffuse endocapillary
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Examples
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Example 1. Nephrotic Syndrome
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IgG
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Example 1
• Nephrotic patient
• Thick loops
• Spikes on silver
• Granular IgG on IMF
• Subepithelial deposits on EM
• = MEMBRANOUS NEPHROPATHY
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IgG
PLA2R
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Early membranous
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Early membranous
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Early membranous
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Deposit
Tiny spike
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Late membranous - spikes
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Late membranous
Spikes
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Example 2
• 7y old boy
• Nephrotic syndrome
• Steroid resistant
• Normal renal function
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Foot process effacement
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What is the Diagnosis
• ?minimal change disease?
• ?are we sure?
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C3 IgM
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Example 2
• Initially normal light microscopy
• Foot process effacement on EM
• Minimal change disease?
• But steroid resistant
• Further sections taken show segmental
sclerosis in one glomerulus
• Diagnosis: Focal segmental
glomerulosclerosis
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Focal Disease: Focal Segmental
Glomerulosclerosis
• How many glomeruli
will be needed?
– 10?
– 20?
– More?
• Distribution is relevant
– Affected glomeruli are
at the corticomedullary
junction
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Specimen Adequacy
• What is adequate
• Depends on the disease present
– Focal or diffuse
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Glomerular Disease
• Diffuse
– >50% of glomeruli involved
• Focal
– <50% of glomeruli involved
• Global
– The whole glomerulus is involved
• Segmental
– Only part of the glomerulus (one or more segments) is involved
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Sample Adequacy
• In general
• 10 glomeruli considered adequate
• 7 borderline
• Vessels need to be represented
• Important role of tubulointerstitium
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Sample Adequacy
• 1. Will have an effect on
the likelihood on making
the diagnosis in focal
pathologies
– Eg FSGS
– Vasculitis
• 2. Will have an effect on
assessing the severity
(grade) of a pathology
– Eg. Number of crescents in
glomerulonephritis
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Sample Adequacy
• We need enough to:
– Diagnose the condition
– Estimate the severity
of the condition
• Cf percentage of
glomeruli with crescents
• But also:
– To assess the level of
chronic damage
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Example 3
• Male 27
• Microscopic haematuria
• Proteinuria
• Mild renal impairment
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IgA - immunofluorescence IgA - immunoperoxidase
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IgA nephropathy
• Mesangial
hypercellularity
• Sometimes
proliferation in the
loops
• Sometimes crescents
• Defined by the
imunohistochemistry
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IgA nephropathy
• Prognostic features
• Degree of mesngial
proliferation
• Presence of endocapillary
proliferation
• Presence of segmental
sclerosis or adhesions
• Level of interstitial fibrosis
• Oxford Score
• M, E, S, T
Adhesion/segmental sclerosis
Mesangial proliferation
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Example 4.
• Female 12
• Nephrotic syndrome
• Haematuria
• Some renal
impairment
• Complement levels
low
• ANA negative
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PAS
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Silver
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Trichrome C3
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IgG C3
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GBM
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Example 4.
• Hyperlobular glomeruli
• Double contouring on silver
• C3 and IgG aroud loops
• Subendothelial deposit on EM
• Membranoproliferative glomerulonephritis
type 1.
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Example 5
• 33 y female
• Nephrotic
• Active urine
sediment
• ANA +ve
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Endocapillary proliferation
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Wire loops
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Haematoxophyll bodies
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Deposits in loops
PAS Silver
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Immunofluorescence
IgG C3
C1q IgM
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Example 5
• Immune complex
glomerulonephritis
• “Full house” IMF
• Full Monty of
morphological
features!
• = Lupus nepritis
• Affects more than 50% of
glomeruli
– All in this case
• Generally the whole
glomerulus is affected
– Global
• It is acute
• No membranous
component
• Class IV-G (A)
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Example 6
• 78y man
• Unwell for six weeks
• Nasal stuffiness
• Creatinine 600
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Example 6
• Focal segmental necrotising glomerulonephritis
• Unaffected glomeruli normal
• No deposits on EM
• Negative immunofluoescence
• (Vasculitis)
• Diagnosis: Pauci-immune (ANCA associated) glomerulonephritis – Eg Wegener’s
granulomatosis
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Leiden Classification in ANCA Associated Glomerulonephritis
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ANCA disease in arteries – rare!
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Assessment of Crescentic
Glomerulonephritis
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Non-affected glomeruli - normal
• ANCA
• Anti – GBM
disease
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Non-crescentic glomeruli show proliferation
• Immune complex
disease
– IgA/HSP
– Lupus
– MPGN
– Post infectious GN
– Fibrillary GN
– Cryoglobulinaemia
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Example 7
• 7y boy
• Heavy proteinuria
• Haematuria
• Renal impairment
• Family history or renal disease
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Collagen Type IV Alpha 5 chain Control Patient
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Alpha 3 Chain
Controll Patient
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Example 7
• Familial nephropathy
• Characteristic GBM abnormalities
• Absent collagen type IV subunits 3 and 5
from the GBM and TBM
• = ALPORT’S DISEASE
– X- linked variant
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Example 8
• 64y female
• recently started on
omeprazole for
gastro-oesphageal
reflux disease
• Acute renal failure
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Tubilitis
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Example 9
• 44y man
• Known ulcerative
colitis
• Low level proteinuria
• Creatinine 350
• On mesalazine
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Interstitial fibrosis -
trichrome
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Examples 7 and 8 – acute and
chronic tubulointerstitial nephritis
• Defined by the presence or absence of fibrosis
• We need enough tissue to estimate the level of
fibrosis and tubular atrophy
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Chronic Renal Disease
• All renal disease will progress to interstitial
fibrosis and tubular atrophy (IFTA)
• In all renal disease the strongest predictor
of prognosis is the level of IFTA
• We need enough tissue to estimate the
level of fibrosis and tubular atrophy
• Pathologists are not very good at
estimating the level of IFTA
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Chronic Renal Disease
• Final outcome – end stage kidney disease (ESKD)
• May be impossible to determine the original pathology
• Sometimes we can suggest diagnosis or whether glomerular, TI or vascular in origin
• Very little effect on current treatment
• The importance is for transplantation
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Assessment of Renal Disease in
the Human • Assessment is multimodal
• Clinical setting highly important
• Knowledge of renal medicine is essential
• Consider wide variety of diseases
• Often several pathologies present in one biopsy (patient)
• These may be of differential importance – eg pauciimmune glomerulonephritis with incidental
IgA nephropathy
• And may interact with one another – eg IgA nephropathy, diabetes and hypertension
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Summary – Assessment of Renal
Disease in the Human
• Adequate sample needed
– To make the diagnosis
– To assess the severity of the pathology (grade)
– To assess the stage of the disease
• Clinicopathological correlation is paramount!
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Thank you
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Systemic Example
• Diabetes and
hypertension
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