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Anti-Glomerular Basement Membrane

A 19-year-old Caucasian male patient presented with acute renal failure. Serum creatinine was 4.9 mg/dL and he had hematuria and non-nephrotic range proteinuria. Anti-GBM serologic testing was positive. No ANCA detected. Figure 1 one shows a cellular crescent filling Bowman’s space. Figure 2 also shows a cellular crescent associated with a prominent break in Bowman’s capsule (red arrow). Immunofluorescence shows global linear IgG staining of the capillary walls (Figure 3).

Oxalate Nephropathy

H&E stained section (Fig. 1) demonstrating acute tubular injury with frequent translucent intratubular crystalline deposits on a background of severe tubulointerstitial scarring. The crystals show birefringence under polarized light (Fig. 2) characteristic of renal oxalosis. After the biopsy, this 60-year-old male admitted consumption of small quantities of ethylene glycol over the past 16 months.  Other causes of secondary renal oxalosis include enteric forms (Crohn’s disease, celiac sprue, pancreatic insufficiency, small intestinal or gastric bypass or resection), over-ingestion of oxalate containing foods (e.g., dark leafy vegetables, rhubarb, kale, starfruit, tea, spinach, sesame seeds, almonds, peanuts, beets, buckwheat flour, chocolate soy milk),...

Diagnose This! (April 24, 2017)

What is the finding shown and what disease does this likely represent?     ​   ​ ​   ​   ​ ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​ ​   ​ ​   ​ ​   ​...

Arkanines: Truman

Meet Truman! He belongs to our director, Dr. Walker (and our real boss, Mrs. Gail). Truman enjoys going to daycare, playing in a mud pit, eating chicken jerky, and having goat's milk on top of his dog food.

Myoglobin Casts

A 54-year-old man with a history of hypertension and hypercholesterolemia presented with complaints of generalized “muscle stiffness” and cola-colored urine. He was found to have markedly elevated serum creatinine and creatine kinase levels. A renal biopsy showed acute tubular injury with numerous pigmented casts (Fig 1), which were proven to be myoglobin casts by immunohistochemistry (Fig 2). The etiology of the patient’s myoglobinuria was thought to be statin medication, the dose of which had recently been increased. Here is a link to a recent article describing the morphologic spectrum of myoglobin casts in renal biopsies:

Pushing Glass (April 18, 2017)

A 45 year-old man received renal transplantation for HCV-associated end stage renal disease. He is currently treated with Sofobuvir, Tacrolimus and ACEI. He developed renal function impairment (Serum Cr increased to 2.3 mg/dL) with mild proteinuria. Based on the renal biopsy images, which is the most likely diagnosis? A. Severe acute tubular injury due to Sofobuvir B. Calcineurin inhibitor toxicity C. Polyomavirus nephropathy D. Tubular injury secondary to cryoglobulinemia E. Diabetic nephropathy     The answer is B. The light microscopic examination demonstrates isometric vacuolization of tubular epithelial cells, severe hyaline arteriolopathy and a striped pattern of fibrosis. These features...

Diagnose This! (April 17, 2017)

What is this stain and what does this finding mean in a transplant patient (Hint: It’s not a vascular marker).     ​   ​ ​   ​   ​ ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​ ​...

Necrotizing Vasculitis

Necrotizing vasculitis as shown using fluorescence with DAPI-FITC-Texas Red excitation on an H&E stained section. Subtle and not so subtle necrotizing areas are seen easily using this fluorescence technique. The section shows necrotizing vasculitis in an 87-year-old male who presented with hematuria, proteinuria and a creatinine of 2.5 mg/dl. Following the biopsy, ANCA serologies were ordered with cANCA positivity.


Photomicrographs show extensive interstitial and glomerular deposition of Congo red positive material that stains positive for LECT2. Despite being one of the most recently described amyloid proteins, amyloid composed of leukocyte chemotactic factor 2 (ALECT2) is actually quite prevalent. Two large case series focusing on renal amyloidosis have identified ALECT2 as one of the most common forms of amyloidosis involving the kidney along with AL and AA amyloid.1-4 Additionally, a large case series in the liver identified it as the second most common form of hepatic amyloidosis.5 The vast majority of patients suffering from this disease in the United States...


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