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Disease Week: Onco-Nephrology

Article
The rapidly evolving field of oncology and cancer management creates unique opportunities as well as challenges for the nephrology community.  As such, it is important for nephrologists and nephropathologists to be informed and involved in its many aspects in order to better care for patients and be valuable members of a multidisciplinary cancer care team.  The renal manifestations and complications of cancer are myriad and include acute as well as chronic kidney injury, electrolyte/acid–base disturbances, direct injury of the kidney through tumor infiltration and/or paraneoplastic substances, pharmacokinetics of chemotherapeutic agents, and hematopoietic cell transplantation-related kidney injury.  Kidney transplant patients also...
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Art of Medicine: Collapsing Glomerulopathy

Article
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...
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Diagnose This! (January 29, 2018)

Article
What is your diagnosis? Immunofluorescence is negative.     ​   ​ ​   ​   ​ ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​   ​ ​   ​ ​   ​ ​   ​ ​     ​  ...
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Malignant Hypertension

Article
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...
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Pushing Glass (October 10, 2017)

Article
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...
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Opana

Article
The histologic features of thrombotic microangiopathy (TMA) associated with intravenous abuse of extended-release oxymorphone hydrochloride (Opana ER) are shown in these photomicrographs. Medium-power view of an interlobular-sized artery shows severe mucoid intimal edema and associated fractured RBCs (arrow). Adjacent glomeruli show ischemic basement membrane wrinkling. A high-power view of same biopsy specimen shows near-luminal occlusion of an interlobular-sized artery secondary to severe endothelial cell swelling and mucoid intimal edema. By electron microscopy, glomerular basement membranes showed marked subendothelial electron-lucent expansion (arrow). Oral extended-release oxymorphone hydrochloride (Opana ER) is an opioid agonist that has undergone a tamper-resistant reformulation. A report by...
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Thrombotic Microangiopathy

Article
This biopsy is from a person in their 40’s, who presented with accelerated hypertension and blood pressure of 240/180 mm/Hg. Urinalysis showed 2+ protein and 2+ blood and his serum creatinine was 7.2 mg/dl. Further workup revealed a low platelet count at 90,000 and schistocytes on peripheral smear. He was admitted to the ICU where careful hypertension management was instituted. Serologies were negative for ANA, cANCA, pANCA, anti-GBM, and hepatitis B and C. Complements were normal. ADAMTS-13 was normal. Diagnosis: Thrombotic Microangiopathy Global Glomerulosclerosis (20/72). Interstitial Fibrosis, Severe. Arteriosclerosis and Arteriolar Hyalinosis, Severe. Discussion: Thrombotic microangiopathy is a pattern that...
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