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Archive: July 2019

Twitter Poll (July 24, 2019)

ANSWER: B Decoy cells are epithelial cells containing intranuclear viral inclusions in urine. They are not specific for polyomavirus nephritis, but when present they may indicate polyoma infection of urinary tract. Decoy cells are easily identified in routine Papanicolaou stained urine cytology specimens, and can be identified in unstained sediment by phase-contrast microscopy. In Papanicolaou stained cytology smears, Decoy cells are comet-shaped with large basophilic, amorphous, homogeneous, ground-glass like intranuclear inclusion bodies and a condensed rim of chromatin. REFERENCE: Singh HK, Bubendorf L, Mihatsch MJ, Drachenberg CB, Nickeleit V. (2006) Urine Cytology Findings of Polyomavirus Infections. In: Ahsan N. (eds)...

Dr. Abraham Visit

We are so thrilled to have one of our dearest friends here all week.  Dr. Anila Abraham is a nephropathologist in Chennai, India as well as one of the kindest souls you will ever meet. We just love it when she visits.  :)    

BK Nephritis

The patient is a 45-year-old male with a past medical history significant for ESKD secondary to IgA nephropathy S/P renal transplant (3 years ago). He has been in his normal state of health but presented with an abnormal creatinine of 2.5 mg/dL on routine examination. His BK viral load was elevated at 25,000 copies in the serum. Figure 1 shows a normal glomerulus, figure 2 shows severe interstitial inflammation, figures 3 & 4 show marked tubulitis, and figure 5 shows a SV40 positive stain. This is a case of BK nephritis. BK virions are non-enveloped double-stranded DNA viruses. In immunohistochemistry,...

Zebrafish: How Can They Help Us?

I have enjoyed working with laboratory zebrafish since 2003.  Zebrafish have become a very well accepted model organism for human disease due to rapid breeding, fast development, transparent embryos, and conservation of 70% of human genes.  Several human diseases have been successfully modeled using zebrafish such as acute lymphoblastic leukemia, melanoma, and Duchenne muscular dystrophy. The majority of my time with zebrafish was spent in the Vanderbilt University system where I was involved in diverse research areas such as gastrulation, fetal alcohol syndrome, holoprosencephaly, Menkes Disease, and obesity. I discovered that I like contributing to the discovery or development of...

Art of Medicine: The Pre-Implantation Kidney Biopsy

The painting above shows normal glomeruli, tubulointerstitium, and a normal artery from a pre-implantation wedge biopsy. Pre-implantation wedge biopsies, also known as donor biopsies, procurement biopsies, or harvest biopsies, are performed for extended criteria donor kidneys, high risk recovered donor kidneys, or at the request of the transplant surgeon, to evaluate for suitability for transplantation. Over 40% of procured kidneys are discarded prior to transplantation. The use of preimplantation kidney biopsies, performed as frozen sections at transplant centers, may reduce the discard rate by accepting kidneys that are histopathologically acceptable, as well as to avoid transplantation of sub-optimal organs. “Extended...

Type 1 Cryoglobulinemic Glomerulonephritis

The patient is a 75 year-old female who presents with proteinuria, a necrotic skin lesion on her lower extremity, and a creatinine of 5.5 mg/dL. Her serum complement levels (C3/C4) are low.  Serologies for ANA, dsDNA, rheumatoid factor, c-ANCA, p-ANCA, anti-GBM, and ASO are negative. Her cryoglobulins are positive. Image 1 shows hyaline thrombi and image 2 shows mild interstitial fibrosis. Images 3, 4, 5, and 6 are IgG, IgM, kappa, and lambda, respectively. This is a case of Type 1 cryoglobulinemia. Type 1 cryoglobulins are composed of a single monoclonal immunoglobulin that reversibly participates at low temperature (<37C).  Type...

Membranous Lupus Nephritis

The patient is a 19-year-old female who presents with hematuria, nephrotic range proteinuria, and a creatinine of 1.2 mg/dL. She has a recent diagnosis of systemic lupus erythematosus. Figure 1 shows a normal glomerulus without "spikes" and "holes" of the glomerular basement membranes. Figure 2 shows no significant interstitial fibrosis. Figures 3, 4, 5, & 6 shows IgG, kappa, lambda, and C1q respectively. Image 7 and 8 shows subepithelial deposits. This is a case of membranous lupus nephritis (ISN/RPS Class V). By definition, no proliferative changes (crescents, fibrinoid necrosis, endocapillary hypercellularity) are seen within the glomeruli in a pure class...

Twitter Poll (July 10, 2019)

Answer: True About 5-10% of the patients with monoclonal gammopathy and findings consistent with C3GN by standard IF (on frozen tissue) will actually have a Membranoproliferative GN with masked monoclonal deposits. These patients require additional IF studies to be performed on protease-digested, paraffin-embedded tissue for identification of the monoclonal immunoglobulin in the deposits. References: Leung N, et al. The evaluation of monoclonal gammopathy of renal significance: a consensus report of the International Kidney and Monoclonal Gammopathy Research Group. Nat Rev Nephrol 2019; 15(1): 45-59. Larsen CP, et al. Membranoproliferative glomerulonephritis with masked monotypic immunoglobulin deposits. Kidney Int 2015; 88(4): 867-873....