This presentation i have made to understand the approach to a kidney biopsy in depth. kidney biopsy is not done in all centers and that's why its difficult to understand it. i have put some cases also to understand it better.

1. An Approach to a Kidney biopsy
for a glomerular lesions
Dr. Manan Shah

2. CONTENTS
• Indications of kidney biopsy
• Contra indications
• Tissue sampling
• Tissue Allocation and fixation
• Handling of biopsy tissue
• Tissue Examination
– Injury Localization
– Categories of Injuries
– Types of lesions
• Determination of lesions
• Native kidney specific lesions
• Transplant Kidney lesions
• Case discussions

3. Nephrotic syndrome:
› Adult NS
› Children with atypical features
Acute renal failure:
› Undiagnosed
› Non resolving clinical ATN>3-4
weeks
Systemic diseases with renal dysfunction
Sub-nephrotic proteinuria
› >2g/d in DM, early MGN, FSGS,
IgAN
› <2g/d needs clinicians discretion
Hematuria
› Isolated
› Associated with proteinuria and
abnormal urine sediment
Post transplant
CKD
 generally contraindicated
 In moderate dysfunction-potential
reversibility and basic disease
Diabetes Mellitus
 Microscopic hematuria
 Absence of retinopathy and
neuropathy
 Onset of proteinuria <5years from
diagnosis
 Acute worsening of renal function
 Systemic features

5. TISSUE SAMPLING
• 1. Sample size:
Condition/Diagnosis No. of glomeruli
Focal lesions involving a small number of glomeruli minimum 25
Membranous glomerulonephritis single
Transplant kidney biopsy diagnoses Minimum 7
For most light microscopic assessment 8 - 10

6. • 2. Sample Location:
– Subcapsular:
• It can have over presentation of global sclerosis related
to aging/hypertension and non-specific scarring
– Juxtamedullary glomeruli:
• They are the first to involve with segmental sclerosis in
FSGS. So they should be there in the sample for
complete evaluation
TISSUE SAMPLING

7. TISSUE ALLOCATION AND FIXATION
• Tissue allocation:

8. TISSUE ALLOCATION AND FIXATION
• Fixation:
Technique Fixative
Light microscopy • 10% Formalin
• Paraformaldehyde
Immunoflorecence • Directly frozen
• Transport media such as
Michel’s.
Electron microscopy Glutaraldehyde.

9. HANDLING OF TISSUE
• No forceps, manipulate with thin woodenstick
to avoid crushartifact.
• Avoid touching tissue with aLM or EM
fixative-contaminated scalpel or razor blade
(this contaminates the tissue for IF).

10. IFINADEQUATETISSUE
• Extra tissue after IF stains:
– The remaining frozen tissue may be fixed in formalin
and processed for LM.
• LM tissue fixed on the paraffin block:
– EM study can be done by processing remaining tissue
on paraffin block
– IF study can sometimes be done satisfactorily in tissue
that has not been in paraffin blocks too long

11. TISSUE EXAMINATION

12. Light
microscopy(LM)
IHC-IF
Electron
Microscopy(EM)
Biopsy Tissue Examination

13. TISSUE EXAMINATION
• Injury Localization:
– Glomerulus
– Vascular
– Tubulointerstitial

14. TISSUE EXAMINATION
• Category of Injury:
– Active Vs Fibrosing
ACTIVE FIBROSING
Proliferation Glomerulosclerosis
Necrosis Fibrous crescent
Crescents Tubular atrophy
Edema Interstitial fibrosis
Active inflammation (glomerulitis,
tubulitis, vasculitis)
Vascular sclerosis

15. TISSUE EXAMINATION
• Types of lesion:
– Nature and pathogenesis of diseases
– Approach to a specific diseases

16. NATURE AND PATHOGENESIS OF
DISEASES
• Light Microscopy
– Character of lesion
– Special stain: Deposits or not.
• Immunofluorescence
– Immune complex or not
• Electron microscope
– Immune complex or not
– Localization of injury
– Nature of any deposits
– GBM abnormalities
– Foot process effacement

17. SPECIFIC GOMERULAR LESIONS and
ITS APPROACH
• Basement membrane thickness
• Proliferation
• Sclerosis
• Crescents formation
• Unusual lesions- Rare diseases

18. BASEMENT MEMBRANE THICKENING
Thickened GBM
Negative IF
Silver stain
1) No splitting
of BM
2) Thick lamina
densa by EM
Diabetic
Nephropathy
Splitting
of BM
Chronic
thrombotic
microangiopathy
Transplant
glomerulop
athy
Positive IF
Granular
capillary loop
staining by IF,
spikes by
Jones’ stain,
subepithelial
deposits by
EM.
membranous
GN
Molded,
sausage-
shaped
contour of
deposits along
capillary loop,
mesangial
granular
deposits, GBM
splitting by
silver stain,
subendothelial
deposits by
EM
membranoproliferativ
e glomerulonephritis
GBM variable
splitting by
silver stain,
fibrils by EM,
negative
Congo Red
fibrillary
glomerulon
ephritis
Variable
IF: with
congo red
positive
and fibrils
by EM
amyloid

19. DIABETIC NEPHROPATHY

20. DIABETIC NEPHROPATHY

21. MEMBRANOUS GLOMERULONEPHRITIS

22. BASEMENT MEMBRANE THINNING
• Benign Familial Hematuria
– Familial History
• Alport syndrome (Irregular- thick and thin)
– Sex
– Immunostaining for subtype of type 4 collagen.
(Most common α5 gene mutation)

23. PROLIFERATION
1. Mesangial proliferation with nodules.
2. Mesangial proliferation without nodules.
3. Non-specific mesangial proliferation.
4. No deposites by IF/EM.
5. Mesangial Plus endocapillary proliferation.

24. Terminology
Normal Segmental Global
Focal Diffuse

25. Mesangial proliferation with nodules.
• It seen usually associated with sclerosis
Proliferation with nodules
Nodular sclerosis
+
Thick GBM
+
Ateriolar
hyainization
And
No deposites on IF
Diabetic
nephropathy
Nodular
sclerosis
+
λ/κ staining of
glomerulus
+
Amorphous
deposits by EM
Light chain
deposition
disease
+/- Nodular
+
Splitting of BM on LM
+
Capillary loop &
mesangial deposites
by IF
+
Subendothelial
deposites by EM
Membranoproliferative
glomerulonephritis
Relativrly acellular
+
Feathery spikre of
GBM
+
Fibrils on EM
+
Congo red Positive
Amyloid
Idiopathic
nodular
sclerosis

26. Mesangial proliferation without nodules.
Proliferation without nodules
Clinical history
+
Positive for all 3 Ig and both
complements
(full house)
+
Reticular agreegates in
endothelial cells
Mesangial proliferative
lupus nephritis
(type 2 LN)
IgA positivity on IF
+
Mesangial deposits by
EM
IgA Nephropathy
IgG+ C3
+
mesangial deposites
+
Subendothelial hump shaped
deposites by EM
+
PMNs infiltrate in tuft
Post infectious GN

32. DIABETIC NEPHROPATHY

33. DIABETIC NEPHROPATHY

34. • Lupus nephritis class II. Light micrograph of a
glomerulus with mild mesangial hypercellularity
(PAS stain)

36. Focal and segmental proliferation

37. NONSPECIFIC MESANGIAL PROLIFERATION
(NO IMMUNE COMPLEXES)
• could be,
– variant of minimal change disease/FSGS,
– early diabetic nephropathy,
– nonspecific

38. NO DEPOSITS BY IF/EM.
• EM can show extensive FP effacement in MCD
or
• FSGS or GBM thickening in early diabetic
nephropathy

39. MESANGIAL PLUS ENDOCAPILLARY PROLIFERATION
Mesangial + endocapillary proliferation
IgM
+
Pas +ve Pulgs in
Capillary lumens
(Cryoplug)
Cryoglobulinemic
glomerulonephritis
IgG+ C3
+
mesangial
deposites
+
Subendothelial
hump shaped
deposites by
EM
+
PMNs infiltrate
in tuft
Post
infectious
GN
+/- Nodular
+
Splitting of BM on
LM
+
Capillary loop &
mesangial deposites
by IF (IgG)
+
Subendothelial
deposites by EM
Membranoproliferative
glomerulonephritis type 1
Dense deposits by
C3
+
Dense
transformation of
GBM
+
Mesangial nodules
on EM
MPGN type 2
(Dense
deposite
disease)
Clinical
history
+
Positive for
all 3 Ig and
both
complemen
ts
(full house)
+
Reticular
agreegates
in
endothelial
cells
MPLN

45. MESANGIAL PLUS ENDOCAPILLARY
PROLIFERATION.
• Fibrillary GN:
– Ig G Predominance
– EM: Fibrillary substance
• Immunotactoid GN:
– IgG Predominance
– Deposits along with microtubuls on EM
– Associated with Paraprotein

46. SCLEROSIS
SCLEROSIS
Usual Type sclerosis
+
Foot process effacement
by EM
FSGN
collapse and retraction of
glomerular tuft
+
Segmental/Global involvement
+
Podocytes proliferation
+
Some time HIV Association seen
Collapsing GS
Seconadry sclerosis
1) Positive Immune complex: IgA
Nephropathy
2) Retracted tuft with adhesion
and fibrous cresents,
periglomerular fibrosis: Advanced
Lupus nephritis

49. CRESCENTS
Crescents
Immune etiology
Linear Ig G stain
of GBM
Anti- GBM
antibody-
mediated GN
Other immune
complex
positivity
1) Lupus
nephritis
2) PIGN
3) IgA
nephropathy
Pauci-immune
Minimal/no
deposites by
IF/EM
Wegener granulomatosis
Or
Microscopic polyangitis

53. UNUSUAL LESIONS- Rare diseases
Unusual lesions- Rare diseases
1) Enlarged and bubbly,
clear vacuoles in
mesangial cells,
endothelial cells, vascular
smooth muscles, DCT cells
2)Foamy podocytes and
myelin body type inclusion
on EM
Fabry diseases
Intraglomerular
foamy
macrophages
+
Secondary
sclerosis
LCAT deficiency
Abundent type
3 banded
collagen by EM
Type collagen 3
Glomerulopathy

54. Fabry disease

55. TRANSPLANT KIDNEY GLOMERULAR
LESIONS
• Glomerulitis
– Increase PMNs/Mononuclear cells
• Viral infection
• RENAL VEIN THROMBOSIS
• HUMORAL REJECTION
• Enlarged cells with smudgy nuclei:
– Possible viral infection (CMV)
• Intraglomerular fibrin thrombi
– Ideopathic
– Hyperacute regection
– Recurrence of familial HUS

56. TRANSPLANT KIDNEY GLOMERULAR
LESIONS
• GBM Splitting:
– Transplant Glomerulapathy (no immune deposites)
– Thrombotic microangiopathy (Chronic organizing phase)
– Recurrent/De novo MPGN
• Segmental Sclerosis
– FSGS (no splitting in nonsclerotic area,enhanced foot
process extensively)
– Transplant glomerulopathy ( GBM splitting in non
sclerotic arean less foot processes effacement)

57. TRANSPLANT KIDNEY GLOMERULAR
LESIONS
• Sclerosis with collapsing features
– Cyclosporine toxicity
– Parvo-virus
– Recurrent Collapsing FSGS
– Sever ischemia

58. CASE DISCUSSION

59. Case 1
• 60/M
• H/O weakness
• F/H/O DM
• H/O DM since 15 years
• Peripheral edema
• Vision problems since 1-2 weeks
• Increase frequency of maturation

60. Basic investigation
• CBC: Normal
• Urine routine:
– Increase Albuminurea
– Increase proteinurea
• FBS: 200 mg/dl
• PPBS: 275 mg/dl
• What next?

61. Microscopy

62. DIAGNOSIS?
• Diabetic glomerulosclerosis
– Basement membrane thickening and increased
mesangial matrix in ALL patients
– Diffuse glomerulosclerosis
– Nodular glomerulosclerosis
– Profound hyalinization of afferent arterioles
– Mo splitting of BM on silver stain
– Diffuse thickening of tubular basement
membrane, tubular atrophy and interstitial fibrosis

63. Exudative lesions in DN include glomerular hyalinosis (hyaline cap) (green arrow). In this case
it is accompanied by several Kimmelstiel-Wilson nodules (two of them marked with red
arrows). See, in addition, some atrophic tubules with basement membranes very thickened
(blue arrows). (Masson’s trichrome, X400).

64. Case 2
• 15/M
• Hearing difficulties
• Recent ocular Sx done
• Family history of similar illness in sibling

65. Findings
• Normocytic Normochromic anemia
• Gross haematuria
• RBC cast in urine
• Mild proteinuria
• Microscopy?

66. Immunofluorescence

67. Diagnosis?
• Alport syndrome
– Early: Segmental proliferation or sclerosis of
glomeruli, increased mesangial matrix or cells causing
mesangial widening (detected PAS stain)
– Thinned basement membranes (BM) fail to stain,
while thickened BM may show reduplication
mimicking membranoproliferative glomerulonephritis
– May see fetal type glomeruli, foam cells in glomeruli
or tubules
– Late: Glomerulosclerosis, tubular atrophy

68. Renal tubular cells appear foamy because of the accumulation of neutral
fats and mucopolysaccharides.

69. Case 3
• 25/M
• H/O Respiratory infection 2 weeks back
• No Significant family history
• Gross haematuria
• Mild proteinuria

70. Microscopy

71. DIAGNOSIS?
• IgA Nephropathy
– Diffuse proliferation of mesangial cells and matrix
without significant involvement of capillary walls
or lumina
– Mesangial involvement is often uneven and
resembles focal and segmental glomerulosclerosis
– Normal or hypercellular glomeruli with diffuse
necrotizing crescentic glomerulonephritis

75. Small renal mass biopsy – how, what
and when: report from an
international consensus panel

76. References
• Alexander JH. Handbook of renal biopsy
• Fogo A. An approach to a renal biopsy
• Charles JJ. An algorithmic approach to renal
biopsy interpretation of glomerular diseases
• Michel PM. Renal biopsy, nephrology forum.

77.  THANK YOU 