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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