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This is a renal biopsy from a 62-year-old female with a recent diagnosis of CLL/SLL, who presents with rapidly worsening renal function. The serum creatinine is 4.7 mg/dl (2.7 mg/dl 3 months prior). The biopsy shows a dense multifocal infiltrate of monomorphic small lymphocytes (Fig 1) which stain strongly positive for CD20 (Fig 4) and CD5 (not shown), and negative for CD3 (Fig 3). The background renal parenchyma shows moderate, mixed inflammation with scattered CD3 positive cells. Additionally, the interstitium multifocally shows granulomatous inflammation with giant cells (Fig 2). These findings are consistent with renal involvement by the patient’s know...