RENAL BIOPSY

INTERPRETATION

Dr Bruce LyonsConsultant Histopathologist

Derriford Hospital

(for the MRCPath Exam.)

Biopsy handling

• 2 cores

• 2-3 gloms- IMF/P

• 2-3 gloms- EM

• Rest of tissue- Paraffin

Cutting & Staining

• Paraffin Serials

• H&E: S1 S10 S20

• Sliver (Gomori)

• PAS

• MSB (fibrin)

• EVG

• Congo Red

Cutting & Staining

Immunohistochemistry

• IMF (Frozen)

• IMP (Frozen or

Paraffin)• IgA

• IgG

• IgM

• C3

• C1q

Cases for final MRCPath exam.

• IgA nephropathy / Henoch-

Schonlein Purpura

• Pauci-immune crescentic GN

(Wegener’s, Microscopic PAN)

• Anti-GBM GN (“Goodpasture’s”)

• Lupus (WHO III, IV, V esp)

• Diffuse Membranous GN

• Diffuse Mesangio-capillary GN

• Diffuse Endocapillary prolif. GN

• Minimal Change

• Alport’s

• Thin membrane nephropathy

• [Amyloid/Light chain nephropathy]

• FSGS

• Myeloma cast nephropathy

• TIN vs. Ascending infection

• ATN

• Essential hypertension

• Diabetes mellitus

• Malignant hypertension

• HUS

• TTP

• Scleroderma

• Vasculitis

• Renovascular disease/Embolus

?????????

IgA IgG

Writing a report

• Introduction

• Glomeruli

• Tubules & Interstitium

• Vessels

• Immunohistochemistry

• Electron Microscopy

• Conclusion/Comments:

Renal cases for MRCPath.(the beauty of the Exam. Case)

• ‘Barn-door’ examples

(morphology)

• +/- Common 2° conditions

(esp. vascular)

• ‘Normal’ (looking)

Gathering the information

• ‘Barn-door’ examples

(morphology)

• +/- Common 2° conditions

(esp. vascular)

• ‘Normal’ (looking)

Cases for final MRCPath exam.

• IgA nephropathy / Henoch-

Schonlein Purpura

• Pauci-immune crescentic GN

(Wegener’s, Microscopic PAN)

• Anti-GBM GN (“Goodpasture’s”)

• Lupus (WHO III, IV, V esp)

• Diffuse Membranous GN

• Diffuse Mesangio-capillary GN

• Diffuse Endocapillary prolif. GN

• Minimal Change

• Alport’s

• Thin membrane nephropathy

• [Amyloid/Light chain nephropathy]

• FSGS

• Myeloma cast nephropathy

• TIN vs. Ascending infection

• ATN

• Essential hypertension

• Diabetes mellitus

• Malignant hypertension

• HUS

• TTP

• Scleroderma

• Vasculitis

• Renovascular disease/Embolus

Cases for final MRCPath exam.

• IgA nephropathy/ Henoch-

Schonlein Purpura

• Pauci-immune crescentic GN

(Wegener’s, Microscopic PAN)

• Anti-GBM GN (“Goodpasture’s”)

• Lupus (WHO III, IV, V esp)

• Diffuse Membranous GN

• Diffuse mesangio-capillary GN

• Diffuse endocapillary prolif. GN

• Minimal Change

• Alport’s

• Thin membrane nephropathy

• [Amyloid/Light chain nephropathy]

• FSGS

• Myeloma cast nephropathy

• TIN vs. Ascending infection

• ATN

• Essential hypertension

• Diabetes mellitus

• Malignant hypertension

• HUS

• TTP

• Scleroderma

• Vasculitis

• Renovascular disease/Embolus

IgA IgG

podocyte

endothelial cell

podocyte

endothelial cell

lamina rara externa

lamina rara interna

lamina densa

*

*

Cases for final MRCPath exam.

• IgA nephropathy/ Henoch-

Schonlein Purpura

• Pauci-immune crescentic GN

(Wegener’s, Microscopic PAN)

• Anti-GBM GN (“Goodpasture’s”)

• Lupus (WHO III, IV, V esp)

• Diffuse Membranous GN

• Diffuse mesangio-capillary GN

• Diffuse endocapillary prolif. GN

• Minimal Change

• Alport’s

• Thin membrane nephropathy

• [Amyloid/Light chain nephropathy]

• FSGS

• Myeloma cast nephropathy

• TIN vs. Ascending infection

• ATN

• Essential hypertension

• Diabetes mellitus

• Malignant hypertension

• HUS

• TTP

• Scleroderma

• Vasculitis

• Renovascular disease/Embolus

TIN vs. Infection

Cases for final MRCPath exam.

• IgA nephropathy/ Henoch-

Schonlein Purpura

• Pauci-immune crescentic GN

(Wegener’s, Microscopic PAN)

• Anti-GBM GN (“Goodpasture’s”)

• Lupus (WHO III, IV, V esp)

• Membranous GN

• Mesangio-capillary GN

• Endocapillary proliferative GN

• Minimal Change

• Alport’s

• Thin membrane nephropathy

• [Amyloid/Light chain nephropathy]

• FSGS

• Myeloma cast nephropathy

• TIN vs. Ascending infection

• ATN

• Essential hypertension

• Diabetes mellitus

• Malignant hypertension

• HUS

• TTP

• Scleroderma

• Vasculitis

• Renovascular disease/Embolus

Tubular “Thyroidisation”

Myeloma Cast Nephropathy

Myeloma Cast Nephropathy

Myeloma Cast Nephropathy

• MYELOMA• ‘Hard’, cracked casts

• Giant-cell reaction

• “Thyroidisation”(chronicity)

Cases for final MRCPath exam.

• IgA nephropathy/ Henoch-

Schonlein Purpura

• Pauci-immune crescentic GN

(Wegener’s, Microscopic PAN)

• Anti-GBM GN (“Goodpasture’s”)

• Lupus (WHO III, IV, V esp)

• Membranous GN

• Mesangio-capillary GN

• Endocapillary proliferative GN

• Minimal Change

• Alport’s

• Thin membrane nephropathy

• [Amyloid/Light chain nephropathy]

• FSGS

• Myeloma cast nephropathy

• TIN vs. Ascending infection

• ATN

• Essential hypertension

• Diabetes mellitus

• Malignant hypertension

• HUS

• TTP

• Scleroderma

• Vasculitis

• Renovascular disease/Embolus

Diabetes Mellitus

• Nodular sclerotic lesion:

Kimmelstiel-Wilson (KW)

nodule

• Global (“diffuse”)

sclerotic lesion:

Diabetes Mellitus

DM:

‘Capsular drop’

CR

Cases for final MRCPath exam.

• IgA nephropathy/ Henoch-

Schonlein Purpura

• Pauci-immune crescentic GN

(Wegener’s, Microscopic PAN)

• Anti-GBM GN (“Goodpasture’s”)

• Lupus (WHO III, IV, V esp)

• Membranous GN

• Mesangio-capillary GN

• Endocapillary proliferative GN

• Minimal Change

• Alport’s

• Thin membrane nephropathy

• [Amyloid/Light chain nephropathy]

• FSGS

• Myeloma cast nephropathy

• TIN

• ATN vs. Ascending infection

• Essential hypertension

• Diabetes mellitus

• Malignant hypertension

• HUS

• TTP

• Scleroderma

• Vasculitis

• Renovascular disease/Embolus

Essential HTNAfferent hyaline arteriolosclerosis

Essential HTNLarge arteries: Arteriosclerosis

Essential HTNMedium-sized arteries: Medial hypertrophy

Essential HTN

Medium & Small arteries: Internal elastic reduplication

Essential HTN

Medium & Small arteries: Internal elastic reduplication

Essential HTNAfferent hyaline arteriolosclerosis

Cases for final MRCPath exam.

• IgA nephropathy/ Henoch-

Schonlein Purpura

• Pauci-immune crescentic GN

(Wegener’s, Microscopic PAN)

• Anti-GBM GN (“Goodpasture’s”)

• Lupus (WHO III, IV, V esp)

• Membranous GN

• Mesangio-capillary GN

• Endocapillary proliferative GN

• Minimal Change

• Alport’s

• Thin membrane nephropathy

• [Amyloid/Light chain nephropathy]

• FSGS

• Myeloma cast nephropathy

• TIN

• ATN vs. Ascending infection

• Essential hypertension

• Diabetes mellitus

• Malignant hypertension

• HUS

• TTP

• Scleroderma

• Vasculitis

• Renovascular disease/Embolus

Thrombotic Microangiopathy (TMA)

• 4 causes (for the exam!)

• Malignant HTN

• HUS

• TTP

• Screroderma ‘crisis’

Thrombotic Microangiopathy (TMA)

• “Acute” TMA

• TMA heals with “onion-

skinning” (myxoid

fibroblastic thickening)

ATN

• Can be overlooked

(“normal-looking”

biopsy)… but not in the

exam!

Cases for final MRCPath exam.

• IgA nephropathy/ Henoch-

Schonlein Purpura

• Pauci-immune crescentic GN

(Wegener’s, Microscopic PAN)

• Anti-GBM GN (“Goodpasture’s”)

• Lupus (WHO III, IV, V esp)

• Membranous GN

• Mesangio-capillary GN

• Endocapillary proliferative GN

• Minimal Change

• Alport’s

• Thin membrane nephropathy

• [Amyloid/Light chain nephropathy]

• FSGS

• Myeloma cast nephropathy

• TIN vs. Ascending infection

• ATN

• Essential hypertension

• Diabetes mellitus

• Malignant hypertension

• HUS

• TTP

• Scleroderma

• Vasculitis

• Renovascular disease/Embolus