docrenal biopsy interpretation
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renal biopsy interpretation
RENAL BIOPSY INTERPRETATION (for the MRCPath Exam.) Dr Bruce Lyons Consultant Histopathologist Derriford Hospital 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 / HenochSchonlein 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 / HenochSchonlein 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/ HenochSchonlein 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 lamina densa lamina rara externa lamina rara interna endothelial cell * Cases for final MRCPath exam. • • • • • • IgA nephropathy/ HenochSchonlein 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/ HenochSchonlein 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/ HenochSchonlein 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/ HenochSchonlein 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 HTN Afferent hyaline arteriolosclerosis Essential HTN Large arteries: Arteriosclerosis Essential HTN Medium-sized arteries: Medial hypertrophy Essential HTN Medium & Small arteries: Internal elastic reduplication Essential HTN Medium & Small arteries: Internal elastic reduplication Essential HTN Afferent hyaline arteriolosclerosis Cases for final MRCPath exam. • • • • • • IgA nephropathy/ HenochSchonlein 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 “onionskinning” (myxoid fibroblastic thickening) ATN • Can be overlooked (“normal-looking” biopsy)… but not in the exam! Cases for final MRCPath exam. • • • • • • IgA nephropathy/ HenochSchonlein 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