Renal Pathology - Budapest Nephrology Schoolbns-hungary.hu/documents/18bns/2011bns_0831_0945.pdf ·...
Transcript of Renal Pathology - Budapest Nephrology Schoolbns-hungary.hu/documents/18bns/2011bns_0831_0945.pdf ·...
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Renal Pathology
Tibor Toth
2011
BUDAPEST
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I. Anatomy, Histology
II. Glomerular lesions
- important morphologic terms
III. Diagnostic algorhytm
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2011.09.21. 12
Electronmicroscopy Electronmicroscopy
Immune microscopy Light microscopy
HxE
PAS
PAAG
Congo red
E v Gieson
MSB
IgA
IgG
IgM
C3
C1q
Kappa
Lambda
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Categorisation of
glomerulonephritis,
glomerulopathies
(eg diabetes mellitus, amyloid, hereditary renal disease),
interstitial nephritis,
renal vascular disease,
toxic nephropathy
Detect Acute (reversible) vs chronic (irreversible) changes
(e.g.aggressive immune suppression yes/no)
Diagnosis of superimposed second kidney disease, e.g.
IgA-GN after Wegener’s granulomatosis,
Wegener’s granulomatosis + Goodpasture, etc.
Monitoring transplant rejection.
Renal biopsy - Interpretation
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Mesangium
Capillary loop
Parietal
epithelial cell
Podocyte
Endothelial cell
Bowman’s capsule
GBM
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2011.09.21. 17 2011.09.21. 17
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Analysis of the renal
biopsy sample
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HE-stain (hematoxylin-eosin)
composition of tissue:
cortex vs medulla,
number of glomeruli
cellular infiltrates ..
analysis of glomerulus and vessels:
glomerular cells,
mesangial matrix
glomerular basement membrane
Routine stains
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Hematoxylin and eosin(H&E)
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Periodic Acid Schiff reaction
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PAAG, PA-Methenamine –silver
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PAAG, PA-Methenamine –silver
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Trichrome- stain
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Elastica-van Gieson- stain
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Congo red staining
Under polarizing light
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IMPORTANT TERMS
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Glomerular changes
Diffuse Focal
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Glomerular changes
Global Segmental
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Proliferative
Implies multiplication in loco
resident glomerular cells.
Exudative Implying inflammatory cells
neutrophils and monocytes
Hypercellularity More cells than normal in glomerulus.
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Mesangial
K-W nodule
mesangiolysis
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Mesangial cell interposition
Mesangialisation
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Tram tracking
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Wire-loops
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A lesion composed of cellular and/or fibrous tissue proliferation which fills all of part of Bowman’s space.
Glomerular crescent
Cellular and fibrocellular
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Glomerulosclerosis
Scarring of a glomerulus due to any chronic process.
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acute process, including vascular disease.
Necrosis
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Immune reaction
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Linear pattern Granular pattern
Immune reaction
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• the diagnosis of other
diseases is confirmed
or refined by IH.
• Some diseases, such
as IgA nephropathy
and anti-GBM-
glomerulonephritis
can only be
diagnosed by IH,
whereas
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ELECTRONMICROSCOPY
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Protein deposits
intraglomerular localisation
ELECTRONMICROSCOPY
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subepithelial
hump
subendothelial
intramembranous
mesangial
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dense deposit disease
Transplant recurrence: 100%
C3
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There is more information in the biopsy
than the diagnosis
The biopsy can provide:
1. Prognostic information
2. An indication of what treatment should be given
and the likely response
3. Give a measurement of activity and chronicity
Renal biopsy (Glomeruli)
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Algorhytmic approach to the
interpretation of renal biopsy
Based on the work of
Zhou, XJ, Laszik, Z, Silva, FG
Silva’s Diagnostic Renal Pathology
Cambridge Univ. Press 2009
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Glomerular changes Diffuse Focal
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Global Segmental
Glomerular changes
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Glomerular changes
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Glomerular changes
NORMOCELLULAR HYPERCELLULAR
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Abnormal capillaries Normal capillaries
Glomerular changes
NORMOCELLULAR
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Normal capillaries
Glomerular changes
NORMOCELLULAR
Haematuria Nephrotic
syndrome
Electronmicroscope
Immunohistology
Specials staining
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Normal capillaries
Glomerular changes
NORMOCELLULAR
Nephrotic
syndrome
Special staining (Congo red+ Polarizing)
Amyloidosis
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Normal capillaries
Glomerular changes
NORMOCELLULAR
Nephrotic
syndrome
IH negative
Minimal change nephropathy
Membranous GN Stage IV Membranous GN Stage I
IH: granular IgG, C3 deposits
EM: subepithelial e.d.deposits
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Normal capillaries
Glomerular changes
NORMOCELLULAR
Haematuria
Alport sy. Thin GBM D IgA N EM IH
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Abnormal capillaries
Glomerular changes
NORMOCELLULAR
Collapse/sclerosis Thickening Occlusion
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Abnormal capillaries
Glomerular changes
NORMOCELLULAR
Collapse/sclerosis Thickening Occlusion
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Abnormal capillaries
Glomerular changes
NORMOCELLULAR
Collapse/sclerosis
Segmental Global
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Abnormal capillaries
Glomerular changes
NORMOCELLULAR
Collapse/sclerosis Thickening Occlusion
Normal
Mesangium
Mesangial expansion
Membranous glomerulopathy
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Abnormal capillaries
Glomerular changes
NORMOCELLULAR
Collapse/sclerosis Thickening Occlusion
Mesangial expansion
DM (900nm)
Control (270 nm)
Diabetes glomerulopathy
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Abnormal capillaries
Glomerular changes
NORMOCELLULAR
Collapse/sclerosis Thickening Occlusion
Mesangial expansion
Amyloidosis
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Abnormal capillaries
Glomerular changes
NORMOCELLULAR
Collapse/sclerosis Thickening Occlusion
Mesangial expansion
Congo red Mean diameter: 19.3 +2.1 nm
Fibrillary glomerulopathy
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Abnormal capillaries
Glomerular changes
NORMOCELLULAR
Collapse/sclerosis Thickening Occlusion
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Abnormal capillaries
Glomerular changes
NORMOCELLULAR
Occlusion
TTP (TMA)
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Abnormal capillaries
NORMOCELLULAR
Occlusion
DIC
Glomerular changes
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Abnormal capillaries
NORMOCELLULAR
Occlusion
Glomerular changes
Cryoglobulinemic GN
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Abnormal capillaries
NORMOCELLULAR
Occlusion
Glomerular changes
Amyloidosis
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Glomerular changes
NORMOCELLULAR HYPERCELLULAR
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Glomerular changes
NORMOCELLULAR HYPERCELLULAR
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Glomerular changes
HYPERCELLULAR
Extracapillary Endocapillar
y
Mesangial
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Glomerular changes
HYPERCELLULAR
Mesangial
IgAN and HSPN
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Glomerular changes
HYPERCELLULAR
Mesangial
Lupus Nephritis Class II.
C1q
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Glomerular changes
HYPERCELLULAR
Mesangial
Resolving postinfectious
GN
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Glomerular changes
HYPERCELLULAR
Endocapillary
Diffuse Focal
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Glomerular changes
HYPERCELLULAR
Endocapillary
Diffuse
Acute postinfectious GN
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MPGN
Glomerular changes
HYPERCELLULAR
Endocapillary
Diffuse
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LN Class IV.
Glomerular changes
HYPERCELLULAR
Endocapillary
Diffuse
C1q
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Focal
Lupus N Class III. Infectious endocarditis IgA N
Glomerular changes
HYPERCELLULAR
Endocapillary
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Glomerular changes
HYPERCELLULAR
Extracapillary
IF negative IF positive
ANCA+ ANCA-
Idiopathic
vasculitide
s
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IF negative
ANCA+
Pauci immune GN
Microscopic polyangiitis
Wegener’s granulomatopsis
Churg-Strauss syndrome
Glomerular changes
HYPERCELLULAR
Extracapillary
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IF positive
Linear pattern Granular
pattern
Glomerular changes
HYPERCELLULAR
Extracapillary
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Linear pattern
Goodpasture’s
syndrome Anti-GBM GN
IF positive
Glomerular changes
HYPERCELLULAR
Extracapillary
IgG
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IC mediated GN
Granular
pattern
IF positive
Glomerular changes
HYPERCELLULAR
Extracapillary
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Thank you for your attention