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Resolving Membranous Nephropathy

Article
Arkana Laboratories, renal pathology, 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....
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Type 1 Cryoglobulinemic Glomerulonephritis

Article
Type 1 Cryoglobulinemic Glomerulonephritis, arkana laboratories
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...
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KDIGO Connections: Membranous Glomerulopathy

Article
KDIGO, Membranous Glomerulopathy, KDIGO Connections, renal pathology
Welcome to the first post in our new series KDIGO Connections, a series in which we are asking our nephrologist colleagues to educate us in real-world experiences treating kidney disease. In this series, Dr. David Bourne will be kicking it off with KDIGO guidelines for a kidney disease in visual abstract form. Our hope is that these posts will foster discussion regarding these diseases and how different providers approach them. Please share any points, pearls, questions, caveats, thoughts, or experience you have on the presented disease letting us all learn from your experience!  
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Infection-Associated Glomerulonephritis

Article
Infection-Associated Glomerulonephritis in renal biopsy
This biopsy is taken from a 39-year-old woman who presents with abdominal pain, ascites, and lower extremity edema. Her serum creatinine is 3.9 mg/dL and her complete blood count shows leukocytosis (14,500). Initial serologic workup is negative. The biopsy shows a diffuse proliferative glomerulonephritis characterized by global endocapillary hypercellularity with prominent neutrophils, best visualized using methenamine silver staining (Fig. 1). No crescents, necrotizing lesions, or significant double contours are identified. By immunofluorescence, there is coarsely granular (3+) capillary wall and less prominent mesangial staining for IgG, C3, kappa, and lambda (Fig. 2). Electron microscopy shows global endocapillary proliferation and numerous...
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Pushing Glass (September 7, 2017)

Article
type 1 cryoglobulinemia, renal biopsy, kidney disease, arkana laboratories, pushing glass
The patient is a 75-year-old female who presents with proteinuria and a creatinine of 2.50. She has chronic lymphocytic leukemia, hypertension, and multiple sclerosis. What is the best diagnosis? A. Type I Cryoglobulinemia B. Type II Cryoglobulinemia C. Hepatitis C associated MPGN D. C3 Glomerulonephritis   The best answer is A (type 1 cryoglobulinemia). The biopsy shows a membranoproliferative pattern with IgG lambda restriction. The presence of hyaline thrombi is concerning for cryoglobulinemia. Cryoglobulins are immunoglobulins that precipitate in the cold and dissolve on warming and induce disease via vascular injury and blockage. Three types of cryoglobulins are distinguished based...
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Diagnose This! (August 6, 2018)

Article
Monoclonal Gammopathy of Renal Significance
What is your diagnosis?    ​   ​ ​   ​   ​ ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​ ​   ​ ​   ​ ​   ​ ​     ​   ​   ​ ​...
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Diabetic Glomerulosclerosis with Superimposed Diseases

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severe mesangial matrix expansion with frequent large nodule formation, Diabetic Glomerulosclerosis
Diabetic glomerulosclerosis is one of the most common causes of nephrotic range proteinuria in adults. When the clinical course of these patients is atypical, a renal biopsy is of utmost importance to rule out superimposed or other concomitant diseases. Figure 1 (PAS stain) shows a representative glomerulus from a renal biopsy performed on a 65 year old Caucasian female with longstanding history of type 2 diabetes mellitus, who experienced a sudden increase in proteinuria from a baseline UPCR of 1.2 g/g to 7.5 g/g. The glomerulus shows severe mesangial matrix expansion with frequent large nodule formation, characteristic of diabetic glomerulosclerosis....
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Diagnose This (June 25, 2018)

Article
Membranous Glomerulopathy
What immunofluorescence stain is shown here, what is the immune complex deposition pattern and what disease does it represent?   ​   ​ ​   ​   ​ ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​ ​   ​...
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Membranous with FSGS

Article
Some patients with membranous glomerulopathy also have associated focal segmental glomerulosclerosis (FSGS) lesions. The glomerulus in this biopsy image, for example, shows a prominent area of segmental sclerosis surrounded by mildly thickened capillary loops which have granular IgG deposits by immunofluorescence (see inset). As in other renal diseases, studies have linked the presence of FSGS lesions in patients with membranous glomerulopathy to more severe disease (e.g. higher levels of proteinuria).   Dumoulin A, Hill GS, Montseny JJ, Meyrier A. Clinical and morphological prognostic factors in membranous nephropathy: significance of focal segmental glomerulosclerosis. Am J Kidney Dis. 2003 Jan;41(1):38-48. PMID: 12500220.
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Diagnose This (March 26, 2018)

Article
In the setting of weak C3 (1-2+) only staining by routine immunofluorescence, what is your diagnosis?   ​   ​ ​   ​   ​ ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​ ​   ​ ​   ​...
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