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Archive: June 2017

Diabetic Nephropathy

Protein Insudative Lesions in Diabetic Glomerulopathy Diffuse and nodular glomerulosclerosis is the classic appearance of diabetic glomerulopathy. However, diabetic nephropathy also includes so-called insudative lesions including “Fibrin Caps” and “Capsular Drops”. These lesions are characteristically seen in diabetics with nephrotic range proteinuria and are thought to be the result of ‘insudation’ of protein and other serum products into the space between the cell lining and its supporting basement membrane. In the case of the Fibrin Cap, the lesion is seen between the endothelium and the glomerular basement membrane (Blue Arrows, Jones Silver 400x). Fibrin cap is a misnomer because there...

Chronic Interstitial Nephritis

Chronic interstitial nephritis is a diagnosis made on renal biopsy when interstitial inflammation is present in a background of fibrosis (as depicted here). The differential diagnosis is broad but consists primarily of autoimmune-related and drug-induced etiologies. As opposed to acute interstitial nephritis, which is of relatively recent onset, chronic interstitial nephritis results from a long-standing inflammatory process. The distinction between these two morphologic patterns is made based on the appearance of the background interstitium. If the inflammation is located in areas of fibrosis, as is seen in this case of CIN due to Sjögren’s syndrome, the process is designated CIN...

Cytomegalovirus

The biopsy from this adult kidney transplant recipient shows features of cytomegalovirus (CMV) infection, including prominent enlargement (“cytomegalo-”) of tubular epithelial cells and their nuclei, along with small basophilic inclusions which expand the cell cytoplasm. An immunostain for CMV was also positive for viral antigen. In the kidneys, CMV shows tropism for tubular epithelial and glomerular endothelial cells. The gold standard for the diagnosis of tissue-invasive CMV disease remains the histopathologic identification of the characteristic cytoplasmic and/or nuclear viral inclusions or positive immunohistochemical detection of CMV viral antigens in tissue. Active CMV disease may be donor-derived (iatrogenic) or it may...

FSGS Tip Lesion – Secondary

The patient is a 64-year-old male with a history of diabetes mellitus, hypertension, and hyperlipidemia, who presents with an increased creatinine of 1.8 mg/dl and proteinuria (UPCR 2.5 g/g). Serologic workup is completely negative. A renal biopsy was performed and shows nodular glomerulosclerosis (Fig 1) and arteriolar hyalinosis characteristic of diabetic glomerulopathy. Additionally, the glomeruli focally show areas of segmental glomerulosclerosis associated with endocapillary foam cells. These lesions are located at the take-off point of the proximal tubule (Fig 1) and reminiscent of the glomerular lesions seen in the tip variant of FSGS. Electron microscopy shows mesangial matrix expansion, mostly...

Diagnose This! (June 26, 2017)

What’s your diagnosis?     ​   ​ ​   ​   ​ ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​ ​   ​ ​   ​ ​   ​ ​     ​   ​   ​ ​...

IgG Background Staining in Diabetic Nephropathy

Immunofluorescence staining with IgG in a patient with diabetic nephropathy shows enhanced linear staining along the glomerular basement membranes and all other basement membranes. This includes the tubules and Bowman’s capsule. It also highlights the mesangial nodules. This is non-specific and not to be confused with anti-glomerular basement membrane antibody disease (anti-GBM, also called Goodpasture Syndrome). Diabetic staining is 1+ to 2+ and distributed along all basement membranes. If anti-GBM is also present in diabetic nephropathy, the IgG will be 3+ along the GBMs and the other basement membranes will have the background 1+ to 2+ staining. Sometimes this is...

Hemoglobin

The H&E photomicrographs show acute tubular injury with eosinophilic ‘beaded’ casts (arrow). Immunohistochemical stains were strongly positive hemoglobin in the casts (pictured here) while myoglobin was completely negative. These findings are consistent with hemoglobin cast nephropathy and indicate the presence of intravascular hemolysis. The morphologic lesions present in hemoglobin cast nephropathy are indistinguishable from myoglobin cast nephropathy without immunohistochemical analysis. It is important when staining for suspected hemoglobin cast nephropathy to stain for both hemoglobin and myoglobin as positive hemoglobin staining in a myoglobin cast is commonly present and considered nonspecific. However, the converse is not true and hemoglobin casts...

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

This renal biopsy was taken from an 82-year-old man with acute renal failure and nephrotic range proteinuria. His past medical history included chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). The biopsy shows an involvement of the renal cortex by a monomorphic population of small lymphoid cells, the morphology and immunophenotype of which were diagnostic of CLL/SLL. In addition, glomeruli showed a diffuse membranoproliferative glomerulonephritis (MPGN) pattern of injury with associated immune deposits. In a study by Da’as et al., more than 10% of patients with non-Hodgkin lymphoma developed acute renal failure. More recent work by Kowalewska et al. describes the spectrum...

Arkana Artwork

Here's another great piece we proudly display in our hallway, from one of our talented artist friends! Marianne Hennigar is local, multidisciplinary artist, who happens to be married to one of our physicians, Dr. Randy Hennigar. Find more of her artwork at http://www.mariannehennigar.com/