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Archive: June 2017

Pushing Glass (June 13, 2017)

A 69-year-old African American woman had a kidney biopsy due to CKD III-IV. Her medical history is significant for morbid obesity, diabetes mellitus (>5 years), hypertension (>5 years), coronary artery disease status post stent, hypothyroidism, gout and chronic kidney disease. Her renal ultrasound shows an unremarkable simple left renal cyst and increased echogenicity in both kidneys. Investigations show serum creatinine which has increased to 4.9 mg/dl. Proteinuria is up to 3.7 gm/day. Serological studies are negative. The images are characteristic findings of which of the following: 1. Sarcoidosis 2. Acute Tubular Injury 3. Uric Acid Nephropathy 4. Interstitial Nephritis 5....

Renal Vein Obstruction

This biopsy is from a 60-year-old female, status post renal transplant 5 days prior, who was found to have mechanical obstruction of the renal vein during the surgical revision of the transplanted kidney, without evidence of thrombosis. The biopsy shows marked congestion of the glomerular capillary loops (Fig 1), peritubular capillaries and arterioles, along with margination of neutrophils (Fig 2), interstitial hemorrhage and severe acute tubular injury. C4d is negative and there are no other clinical or morphologic findings suspicious for hyperacute or acute antibody-mediated rejection. Renal vein or artery obstruction is a rare complication of renal transplantation which is...

Class III Focal Lupus Neprhitis

This 9-year-old female was recently evaluated for lymphoid malignancy due to weight loss and intermittent fevers. Following a negative workup for malignancy, further routine studies showed mild hematuria and proteinuria and she was referred to a pediatric nephrologist. The serologic evaluation showed a positive ANA and positive double-stranded DNA, complement C3 borderline low and C4 normal. Urinalysis showed 3-5 RBCs/HPF but no casts with 2+ blood and 1+ protein. Mesangial lupus was suspected but a biopsy was done to rule out activity. Figure 1 -  No fibrosis with diffuse mesangial hypercellularity and focal proliferation but no crescents and no hyaline...

Eosinophil-Rich Inflammation in Diabetic Glomerulopathy

These photomicrographs are from a patient with diabetic nephropathy as evidenced by the Kimmelstiel-Wilson nodules in the glomerulus present on the PAS section. A patchy, interstitial inflammatory infiltrate rich in eosinophils is present, as seen in the H&E stained section. The infiltrate is particularly prominent in areas of fibrosis. No tubulitis is identified in the biopsy. Interstitial inflammation rich in eosinophils is a common finding in diabetic nephropathy. When present, the pathologist is forced to determine if the inflammation warrants a diagnosis of acute interstitial nephritis. This is an important distinction because, if interstitial nephritis is present, the clinician must...

Intimal Arteritis

The image in Figure 1 shows mild intimal arteritis in an allograft biopsy from a patient who had undergone a kidney transplant. Note that the mononuclear inflammatory cells are found beneath the endothelium rather than simply adherent to the endothelial surface, which may be seen with inflammatory cell margination. Remember, too, as reflected in the 2013 revised Banff working classification, that intimal arteritis may be seen in antibody-mediated rejection in addition to T-cell-mediated rejection. In the patient’s biopsy, the additional presence of linear C4d positivity in peritubular capillaries (Figure 2) and the absence of significant interstitial inflammation and tubulitis provided...

FSGS Tip Lesion

This biopsy is from a 35-year-old male with no significant medical history, who presents with sudden onset nephrotic syndrome. At presentation, the UPCR was 8.2 g/g and the serum albumin was 1.1 g/dl. Renal function was preserved (SCr 1.1 mg/dl). The biopsy shows frequent areas of segmental glomerulosclerosis (FSGS), associated with endocapillary foam cells and epithelial cell capping, predominantly involving the takeoff point of the proximal tubule (fig 1). Focally, the areas of segmental sclerosis herniate into the proximal tubule. Immunofluorescence is completely negative within the glomeruli, and electron microscopy (fig 2) shows diffuse epithelial foot process effacement. The findings...

Diagnose This! (June 5, 2017)

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

Arkana Physician Spotlight: Dr. Cossey

Dr. Cossey joined us in 2013 after completing his fellowship training in renal pathology at Arkana Laboratories. Dr. Cossey received his MD and completed his pathology residency at the University of Arkansas for Medical Sciences, Little Rock, AR. Away from the microscope, you can often find Dr. Cossey helping our IT team problem solve, coordinating our conferences, and developing our social media strategies.  Dr. Cossey’s favorite quote is “The surest way to corrupt a youth is to instruct him to hold in higher esteem those who think alike than those who think differently." (Friedrich Nietzsche-The Dawn; sec. 297) Here at...

Chronic Active Tubulointerstitial Nephritis

39 y/o male presents with acute kidney injury, creatinine 3.5 mg/dl. Bland urinalysis, serologic studies negative. Immunofluorescence study of the renal biopsy was negative for all stains. EM showed no deposits and was otherwise unremarkable. 1. Tubulointerstitial nephritis (H&E x100). 2. Lymphocytes, plasma cells, neutrophils and eosinophils (H&E x400). 3. Interstitial inflammation and fibrosis (Trichrome x100) 4. Intact glomerulus (PAS x400). Diagnosis: Chronic Active Tubulointerstitial Nephritis Comment: Most likely drug-induced but other causes include Sjogren’s syndrome, tubulointerstitial nephritis with uveitis (TINU), Behcet’s syndrome, sarcoid among others. Further discussion with the clinician after giving the above pathologic diagnosis: “Oh, that fits...