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Art of Medicine: Thrombotic Microangiopathy

Thrombotic Microangiopathy
The above painting shows a glomerulus containing capillary loop fibrin thrombi, an arteriole with onion-skinning, and acute tubular injury, findings that can be seen in thrombotic microangiopathy.  Morphologic findings of thrombotic microangiopathy that can be seen on a renal biopsy include arteriolar or capillary loop fibrin or platelet thrombi, red blood cell fragmentation within glomerular capillary loops or within arteries, mesangiolysis, endothelial cell swelling,  glomerular basement membrane duplication, mucoid intimal edema of arteries, and a myointimal proliferation surrounding arterioles (onion-skinning like reaction). Thrombotic microangiopathy (TMA) has a wide clinical differential diagnosis, which can have substantial morphologic overlap on a kidney...

Disease Week: Onco-Nephrology

Onco-Nephrology, disease week, arkana laboratories, renal pathology
Monday Onco-nephrology is a rapidly developing area of nephrology designed to help address and prevent kidney problems and the many complex issues that arise in cancer patients. AKI is a common complication in cancer patients. The highest 1-year risk of AKI was seen in patients with kidney cancer (44%), liver cancer (33%), and multiple myeloma (31.8%) in one large population-based cohort study. Patients with distant metastases were at highest risk. https://www.ncbi.nlm.nih.gov/pubmed/21767759 What is the most common glomerular pathology reported in patients with solid tumors? Minimal change disease Membranoproliferative glomerulonephritis Membranous nephropathy Thrombotic microangiopathy   Answer: Membranous nephropathy.  The incidence of cancer was significantly higher in patients with...

Art of Medicine: Collapsing Glomerulopathy

Collapsing Glomerulopathy
The above painting shows a glomerulus with capillary tuft collapse, visceral epithelial cell hyperplasia, and numerous protein resorption droplets within Bowman’s space; findings that can be seen in collapsing glomerulopathy.  A PAS stain from a case of collapsing glomerulopathy is also shown in the photomicrograph below.  Initially, collapsing glomerulopathy was considered a severe form of focal segmental glomerulosclerosis and placed into the Columbia classification. According to the Columbia classification, collapse of at least one capillary loop with obliteration of the lumen and proliferation and hypertrophy of overlying podocytes is sufficient for a diagnosis of the collapsing glomerulopathy.  Tubulointerstitial damage is...

VEGF Inhibitor

VEGF, VEGF inhibitor, arkana laboratories, renal pathology
The patient is a 70-year-old white female who presents with 4 gm/24 hr proteinuria and a creatinine of 1.2 mg/dl. She has colon cancer with metastases to the liver, treated with chemotherapy and Avastin. The patient has recently had anemia, thrombocytopenia, ascites, and a urinary tract infection treated with nitrofurantoin. Her blood pressure has been under good control at 120/80. Figure 1 shows acellular closure of the capillary lumens and a "cotton-candy" appearance of the mesangium. Figures 2 and 3 shows capillary microaneurysms and segmental capillary hyalinosis. Figure 3 additionally shows double contours. Figure 4 shows moderate interstitial fibrosis. Figure...

Diagnose This! (January 29, 2018)

What is your diagnosis? Immunofluorescence is negative.     ​   ​ ​   ​   ​ ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​ ​   ​ ​   ​ ​   ​ ​     ​  ...

Malignant Hypertension

This renal biopsy shown here is from a 25-year-old male who presented with acute kidney injury in the setting of hypertensive emergency (260/140). He has no significant past medical history. Serum creatinine is 3.1 and proteinuria is 3.2 g. Hemoglobin is low but platelet count is normal. This photomicrograph is representative of the changes in the biopsy including vascular microangiopathic changes (arrows) such as intimal edema with associated fibrin thrombi and schistocytes. Glomeruli were ischemic in appearance but did not show involvement by fibrin thrombi. The findings are consistent with those classically described secondary to accelerated/malignant hypertension. However, given the...

Pushing Glass (October 10, 2017)

The patient is a 50-year-old African-American female with a past medical history significant for ESRD secondary to lupus nephritis who presents two weeks after a renal transplant with a delay in graft function. Her creatinine at the time of presentation is 9. She reports feeling fine and does not have any rashes or joint discomfort. A renal biopsy is performed on the transplanted kidney. Which is the best diagnosis? A. Acute Tubular Injury B. Thrombotic thrombocytopenic purpura C. Acute Antibody-Mediated Rejection D. Vasculitis  The correct answer is c (acute antibody-mediated rejection). The biopsy shows a constellation of findings. This includes...