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Case 2
Erik Heyerdahl Strøm
Division of Pathology
Willy Aasebø
Department of Nephrology
Oslo University Hospital, Rikshospitalet Norway
Co-authorLars Ola Thorud
Innlandet Hospital, Lillehammer
Case history -1
Male, born 1955
2002: Nephritis, creatinine >500, SR 120, C-ANCA: positive
Renal biopsy
Initial biopsy native kidney 2002
Fibrocellular crescents
Initial biopsy native kidney 2002
Fibrocellular crescents
Initial biopsy native kidney 2002
Immunofluorescence: Negative
Initial biopsy (EM) native kidney 2002
No electron dense immune deposits
Diagnosis native kidney biopsy 2002
Focal segmental necrotizing glomerulonephritis with fibrocellular crescents without immune deposits.
Consistent with ANCA-related glomerulonephritis as in Wegener’s granulomatosis
Case history -2
Hemodialysis from – August 2002
Kidney transplantation – January 2006
Case history -3
November - December 2008: gradually increased dyspnoea + oedema, anaemia, and fever.
S-creatinine: 120 to 180 µmol/l
C-reactive protein: 15 to 70 mg/l
Protein/creatinine (urine): 60 to 400 mg/mmol
Urine microscopy: Nephritic sediment.
Due to increase in s-creatinine and proteinuria
A graft biopsy was obtained
6 weeks after debut of symtoms
What to consider in a transplant biopsyAcute rejection?
cellular rejection (T-cell mediated)
antibody-mediated rejection (C4d)
Chronic rejection?
Ischemia?
Drug toxicity?
•CNI (CyA, tacrolimus)?
•Antibiotics?
Infection?
•Virus (polyoma, CMV)
•Systemic infection?
De novo nephritis?
Recurrence of native disease?
Other? (Post transplant lymphoproliferative disease - PTLD)
Minimal tubulitis No vasculitis
Biopsy of the transplant
Double contour capillary wallMesangial cell interposition
Transplant glomerulopathy
Necrosis? Thrombotic material?
Cellular crescent
Cellular crescent
Diagnosis based on light microscopy
No acute rejection (C4d negative)
Transplant glomerulopathy
Focal necrotizing glomerulopathy with few cellular crescents (thrombi?)
Immunfluorescence (paraffin block)
C1q C3
IgA, IgG and IgM were negative
Electron microscopy
No glomeruli in the material submitted for EM
EM therefore performed on material retrieved from the paraffin block
Electron microscopy (paraffin block)
Transplant glomerulopathy (doubling of basement membrane)
Electron microscopy (paraffin block)
Mesangial deposits
Subendothelial deposits
Biopsy diagnosis of transplant
No definite acute rejection (i1 t1 v0, C4d negative)
Transplant glomerulopathy as in chronic rejection
Focal necrotizing glomerulonephritis with cellular crescents in 2 of 13 glomeruli (obs thrombi)
Biopsy diagnosis of transplantConsider
Recurrence of Wegener’s granulomatosis
Systemic infection
Thrombotic microangiopathy
Possible diagnosis -1
Thrombotic microangiopathy ?
TTP/HUS?
Thrombotic Microangiopathy after Tx
As a complication to CNI`s: -- 4-6 %. Usually during the first weeks after Tx.
Other medicines
Acute rejection
Infection (viral, bacterial)
Carcinoma
Anti-cardiolipin antibodies
(Associated with OKT3)
Case history -4
Hgb: 9,2. Thrombocytes: 220 109 . Lactate dehydrogenase: 356 U/l, Bilirubin: 15 µmol/l, (Haptoglobine: not analyzed)
No symptoms from CNS
Conclusion: no TTP-HUS!
! Few crescents are found in 5% of HUS!
Possible diagnosis -2
Recurrence of Wegener’s granulomatosis?
ANCA positive vasculitis after TxN=35 with ANCA-associated vasculitis
20: microscopic polyangitis
15: Wegener
Median time from diagnosis to Tx: 25 months
15: ANCA positive at Tx
Overall graft survival 5 years: 94%
Death censored graft survival: 100%
Relapse: Microscopic polyangitis: 1/20, Wegener: 2/15
All relapses: Non-renal Gera M. Kidney int. 2007
Patient and Graft survival after renal transplantation in Wegener, PKD, IgA-nephropathy and diabetes
Schmitt W, Curr Opin Rheumatol, 2003
Case history -5ANCA: negative
PR3 and MPO: <9 (negative)
ANA: negative
Anti GBM: neg
C3 : 1.44 g/l (0.80 – 2.00) (normal)
C4: 0.28 g/l (0.10-0.50) (normal)
Conclusion: No recurrence of Wegener
Possible diagnosis -3
Systemic infection?
Case history -7
Bacterial growth in blood cultures:
- Streptococcus sanguis
Dr. S. Urheim, Dept. of Cardiology, Rikshospitalet
Ultrasound of the heart
Ultrasound of the heart
Dr. S. Urheim, Dept. of Cardiology, Rikshospitalet
Case history -8
Ecco-cardiography: aortic valve with vegetations on all three cusps.
Endocarditis!!!
Possible diagnosis -3b
Renal affection related to endocarditis
Renal disease in infective endocarditis
Embolic disease --
Microbiological emboli Drug-induced disease --Acute interstitial nephritis - antibiotics --Acute tubular necrosis - Aminoglycosides
Postinfectious immune complex-mediated glomerulonephritis
Renal pathological findings in infective endocarditis354 Patients with endocarditis
62: Renal tissue for examination (20+42)
Majumdar A, NDT 2000
Findings in the Kidney Renal biopsy (n=20) Autopsi (n=42) Total (n=62)
Localized infarction 0 19 19
Acute glomerulonephritis 9 7 16
Acute tubular damage 4 8 12
Cortical necrosis 0 6 6
Acute Interstitial nephritis 5 1 6
Pre-existing glom disorder or Hydronephrosis
4 1+1 5+1
Normal Kidney 0 3 3
Postinfectious glomerulonephritisin general
Previously associated with streptococcus.
Now: associated with several infectious syndromes and a wide variety of bacteria, fungi, viruses and parasites.
Postinfectious glomerulonephritisclinical manifestationsAcute Nephritic Syndrome.
--Hematuria, proteinuria, edema, often hypertension, and a mild degree of kidney injury
Rapidly progressive nephritic syndrome
--Rare (4,6% of biopsies). Rapidly increase in s-creatinine. Crescent formation (often limited)
Subclinical or asymptomatic glomerulonephritis
--Low grade proteinuria, microscopic hematuria. 4-19 times as common as “classic acute nephritic syndrome”
Postinfectious glomerulonephritis histological findingsIn light microscopy:
-diffuse exudative proliferation without crescents
-diffuse endocapillary proliferation with crescents
-mild segmental, mesangial proliferation
-membranoproliferative glomerulonephritis
Immunofluorescence:
-most commonly: deposition of C3 often IgG,
-occasionally: IgM, rarely: IgA (except in patients with diabetes-particularly Staphylococcal infections)
- “Full house”: IgG. IgA, IgM, C3, C4 and C1q is frequently reported
Electron microscopy:
-mesangial, subendothelial and ”humps”
Kanjanabuch T, Nature Reviews Nephrology, 2009
Final diagnosis :
Postinfectious glomerulonephritis related to acute endocarditis
Transplant glomerulopathy
Case history -9Treatment: Penicillin + Gentamycin for 6 weeks
13.1-2009: removal of the affected aortic valve: Implant: biological aortic valve
8 months after surgery: S-creatinine: 128 µmol/l Urea: 11.5 mmol/l
Take home message
1: Focal glomerulonephritis with crescents
-----Don’t forget infection !
2: ANCA-associated vasculitis vs. postinfectious glomerulonephritis:
-----Correct diagnosis is pertinent; treatment and outcome different
3: Histological findings must always be considered in concert with clinical findings
Thank you for your attention