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Resolving Membranous Nephropathy

A 40-year-old white male presents with 3 grams/24 hr of proteinuria and swelling around his ankles. He reports that he has had foamy urine over the last 4 months, but was unable to go to a doctor till now because of lack of insurance. Image 1 and image 2 shows irregularly thickened glomerular basement membranes with lamellation. Image 3 shows numerous "holes" on silver stain. Images 4, 5, and 6 show weak staining for IgG, kappa, and lambda, respectively. Membranous nephropathy in a resolving phase can be a tricky diagnosis since the immunofluorescence staining may be extremely weak or negative....

Twitter Poll (September 12, 2019)

ANSWER: B In a case series by Boils et al. which included 49 patients with GN due to IE, the most common biopsy finding was necrotizing and crescentic GN which was found in 53% of the cases. This was followed by endocapillary proliferative GN in 37% of the biopsies. Reference: Boils CL, et al. Update on endocarditis-associated glomerulonephritis. Kidney Int. 2015; 87(6):1241-1249.  

Art of Medicine: Plasma Cell Rich Interstitial Nephritis

The above painting shows plasma cell rich interstitial inflammation with lymphocytic and plasma cell tubulitis, findings that can be seen in plasma cell rich interstitial nephritis.  Acute interstitial nephritis can have an inflammatory infiltrate with lymphocytes, plasma cells, eosinophils, neutrophils, and/or histiocytes.  Greater than 10 percent plasma cells would be considered “plasma cell rich”.  An H & E stained section of a plasma cell rich infiltrate is shown below. The differential diagnosis for a plasma cell rich interstitial nephritis in native kidney biopsies includes drug reactions, Sjögren's syndrome, chronic pyelonephritis, and IgG4-related kidney disease.  IgG4-related kidney disease is characterized by...

Fellowing Joel: Episode 1

This summer Dr. Joel Murphy (@md_murph) started as a fellow here at Arkana. For the remainder of his fellowship, we will be following his journey in a weekly video series called Fellowing Joel! [video width="1920" height="1080" mp4="https://www.arkanalabs.com/wp-content/uploads/Fellowing-Joel-Ep-1-FINAL.mp4"][/video]    

Nucleated Red Blood Cells in Circulation

The patient is a 70-year-old male who presents with a creatinine of 5 mg/dl and a history of primary myelofibrosis. The biopsy shows a kidney with severe glomerular and tubulointerstitial chronicity, approaching end-stage kidney disease from arterionephrosclerosis. Interestingly, circulating nucleated red blood cells were identified in the arteries and peritubular capillaries. Although not representing a specific kidney disease, the presence of nucleated red blood cells within the circulation points toward premature release of erythroid precursors from the bone marrow. This finding is has been reported in the setting of a space-occupying lesion in the bone marrow from metastases or in...

Art of Medicine: Anti-Brush Border Antibody Disease

The above painting shows massive tubular basement membrane (electron dense on EM) deposits along proximal tubules with sparing of the distal tubules.  This is a finding that can be seen by electron microscopy in anti-brush border antibody disease (ABBA).   Tubular basement membrane deposits are also seen in lupus nephritis (all classes), IgG4-associated kidney disease, idiopathic hypocomplementemic interstitial nephritis, polyomavirus nephritis (BK virus or JC virus), or in response to certain medications (eculizumab, NSAIDS, and others).   Interstitial inflammation is not prominent in ABBA disease, as it is with other pathologies with tubular basement membrane deposits (such as IgG4-associated disease, drug reactions,...

Twitter Poll (August 28, 2019)

ANSWER: A Dr. Albert Hewett Coons was an American physician, pathologist, and immunologist who conceptualized and developed the immunofluorescence technique for labeling antibodies in the early 1940s. Renal pathologists acquired this technique for the assessment of medical kidney biopsies, and since then it has become the gold standard on routine evaluation. References: Coons, AH, et al. The demonstration of pneumococcal antigen in tissues by the use of fluorescent antibody. J Immunol 1942; 45: 159-170. Coons, AH. The beginnings of immunofluorescence. J Immunol 1961; 97: 499-503.        

The Strength in Unity

Clap your hands if you are ready to visit Georgia! Yesterday Dr. Tsilosani gave a short presentation which included information about her cultural heritage, her home town, and multiple sightseeing locations in Georgia. She also taught us their flag, main goods, and language.  Booking our plane tickets now...     

Diagnose This (August 26, 2019)

What is your diagnosis?     ​ ​   ​   ​ ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​ ​   ​ ​   ​ ​   ​ ​     ​   ​   ​ ​  ...

HIVICK

The patient is a 24 year-old African American male who has recently been diagnosed with HIV infection. He has not received HAART therapy and presents to the hospital with 1.2 g/g of proteinuria and a creatinine of 2.9 mg/dL. Figure 1 shows segmental sclerosis. Figure 2 shows tubular atrophy and interstitial inflammation. Figure 3 shows "hole" formation in glomerular basement membranes. Figures 4, 5, and 6 shows IgG, kappa, and lambda, respectively. Figure 7 shows mesangial and capillary wall electron dense deposits. This is a case of HIV immune complex disease of the kidney (HIVICK). HIV immune complex disease of...