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Diagnose This (December 10, 2018)

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

Infection-Associated Glomerulonephritis

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...

Diagnose This (April 2, 2018)

What is the most likely diagnosis?   ​   ​ ​   ​   ​ ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​ ​   ​ ​   ​ ​   ​ ​     ​ ​   ​...

Acute Pyelonephritis in Transplants

Acute pyelonephritis in the transplant setting (allograft pyelonephritis) is a known cause of allograft dysfunction and a complication that occurs in approximately 10-16% of transplanted patients. Given the overlap of clinical findings between acute pyelonephritis and rejection, acute pyelonephritis is seen more often in biopsies performed on allografts than on native kidneys. This 32 year old patient presented with increased creatinine (2.6 mg/dl) 2 years after receiving a deceased donor kidney transplant. As shown in Fig 1 and 2, the biopsy shows severe neutrophilic inflammation associated with remarkable rimming of the tubules, neutrophilic tubulitis and neutrophilic casts. These features are...

Renal Vein Obstruction

This biopsy is from a 60-year-old female, status post renal transplant 5 days prior, who was found to have mechanical obstruction of the renal vein during the surgical revision of the transplanted kidney, without evidence of thrombosis. The biopsy shows marked congestion of the glomerular capillary loops (Fig 1), peritubular capillaries and arterioles, along with margination of neutrophils (Fig 2), interstitial hemorrhage and severe acute tubular injury. C4d is negative and there are no other clinical or morphologic findings suspicious for hyperacute or acute antibody-mediated rejection. Renal vein or artery obstruction is a rare complication of renal transplantation which is...

Acute Postinfectious Glomerulonephritis

These renal biopsy images are from an 8-year-old boy who experienced the abrupt onset of hypertension, lower extremity edema, gross hematuria, and proteinuria about one week after seeing his pediatrician for a sore throat. The child had an elevated BUN and serum creatinine, and he was hypocomplementemic (C3). Figure 1 shows a diffuse proliferative (note the hypercellularity and closed capillary loops) and exudative (note the abundant neutrophils) glomerulonephritis. The Jones silver stain in Figure 2 confirms the presence of endocapillary, mesangial, and extracapillary hypercellularity. The immunofluorescence studies in Figure 3 show coarse, granular immune deposits along the peripheral capillary loops...

Acute Pyelonephritis

This renal biopsy from a 65-year-old male with a history of E. Coli urinary tract infection and bacteremia shows severe neutrophil-rich interstitial inflammation with neutrophilic rimming of the tubules, neutrophilic tubulitis and neutrophilic casts (Figures 1-3).  These features are diagnostic of acute pyelonephritis. In addition to the aforementioned morphologic findings, a characteristic feature of acute pyelonephritis is the patchy nature of the infiltrate (Fig 4). Relatively spared areas of renal parenchyma are often intermixed with areas displaying severe tubulointerstitial inflammation.  While an ascending urinary tract infection is the main mechanism for the development of acute pyelonephritis, hematogenous infections may also...

Chronic Active Tubulointerstitial Nephritis

Chronic tubulointerstitial nephritis in children may be secondary to a number of possible etiologies such as drug and other exogenous toxin exposure, infections, lower urinary tract obstruction, autoimmune diseases, nephronophthisis and genetic disorders such as autosomal dominant tubulointerstitial kidney disease due to MUC1, UMOD, REN or HNF1β. Figures 1-3 are representative images from the kidney biopsy of a 15 month old male with a history of prune belly syndrome, status post multiple lower urinary tract procedures and recurrent urinary tract infections. There is severe tubulointerstitial scarring which is disproportionate to the degree of glomerulosclerosis, with a moderate, predominantly chronic, interstitial...

Diagnose This! (August 7, 2017)

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

Acute Pyelonephritis

The renal biopsy image shows features characteristic of acute pyelonephritis. There is a neutrophil-rich interstitial inflammatory infiltrate and evidence of acute tubular injury. Some tubular lumens are filled with neutrophils (arrow), and in some areas, neutrophils encircle the outer aspect of the tubules between the tubular basement membrane and the interstitium (arrowhead). In some cases, micro abscesses may even form (not shown). In most cases of ascending infection, large vessels and glomeruli are uninvolved. If arteritis or neutrophilic infiltrates involve glomeruli, the possibility of a hematogenous infectious source should be considered.