This document summarizes 8 renal biopsy cases from 2001-2005. Case 1 involves a patient with proteinuria and was diagnosed with immunotactoid glomerulonephritis. Case 2 involves a lupus nephritis patient with acute renal failure who was diagnosed with diffuse proliferative lupus nephritis. Case 3 involves a 3-year old boy with hypertension, hematuria and proteinuria who was diagnosed with C1q glomerulopathy.

1. Eight representative
de-identified renal biopsy
teaching cases from 2001-
2005

2. Case 1
Proteinuria. For pilot license certification.

3. .
.

10. IF
• IgG-Mild to moderate mesangial staining.
• IgA-Negative.
• IgM-Mild mesangial staining.
• C3-Moderate mesangial staining.
• C1q-Mild mesangial staining.
• Kappa-Moderate to strong mesangial
staining.
• Lambda-Negative.
• Fibrin-Mild interstitial staining.
• Albumin-Negative.

11. IgG

12. IgM

13. C3

14. Clq

15. Kappa

16. Fibrin

25. Diagnosis:
Renal Biopsy: Kappa light chain
disease with extensive glomerular
deposition of fibrillary microtubular
structures approximately 17 nm in
diameter.
Immunotactoid glomerulonephritis.

26. Case 2
20 yr old female, known lupus nephritis,
class 4, previously treated with IV
cyclophosphamide for 10 months,
admitted with acute renal failure,
evidence of TMA, leukopenia,
oliguria/anuria and fluid overload.
Treated with IV MP x 3d, plasmapheresis
and then started on hemodialysis. Repeat
biopsy done. T.Kovithavongs

27. Lupus – on dialysis. ? Stage. ? Chronic
Or active.

33. IF
• IgG-Moderate to strong coarsely granular capillary loop and mesangial
staining.strong granular peritubular staining.
• IgA- Moderate coarsely granular capillary loop and mesangial staining.
• IgM-Mild to moderate coarsely granular capillary loop and mesangial
staining, mild to moderate granular peritubular staining.
• C3- Mild to moderate coarsely granular capillary loop and mesangial
staining.
• C1q-Moderate to strong coarsely granular capillary loop and mesangial
staining, strong granular peritubular staining.
• Kappa- Moderate to strong coarsely granular capillary loop and mesangial
staining, strong staining of granular capillary wall coagula and moderate
granular peritubular staining.
• Lambda- Stong staning of granular capillary wall coagula and moderate
granular peritubular staining.
• Fibrin- Strong staining of glomerular crescent moderate interstitial staining.
• Albumin-Mild hyaline droplet change in tubular cytoplasm.

34. IgG

35. IgG

36. IgM

37. IgM

38. C3

39. Clq

40. Clq

41. IgA

42. Kappa

43. Kappa

44. Lambda

45. Lambda

46. Fibrin

47. Fibrin

48. Albumin

49. Kappa

50. Lambda

55. Diagnosis:
Renal Biopsy:Diffuse proliferative
lupus nephritis of moderate activity and
mild to moderate chronicity with many
hyaline thrombi and “fingerprints” by
EM in an active acute interstitial
nephritis involving polymorph infiltrates
with peritubular deposits seen by
electron microscopy.
Occasional glomerular capillary and
arteriolar fibrin thrombi.

56. Case 3
3-year-old boy with hypertension.
Hematuria and proteinuria
Serology all negative
Family history of IgA nephropathy

63. IF
• IgG – moderate mesangial staining.
• IgA – negative.
• IgM – mild to moderate mesangial staining.
• C3 – mild vascular staining.
• C1q – mild to moderate mesangial staining.
• Kappa – mild to moderate mesangial staining.
• Lambda – mild mesangial staining.
• Fibrinogen – negative.
• Albumin – negative.

64. IgG

65. IgM

66. C3

67. C1q

68. Kappa

69. Lambda

73. DIAGNOSIS
• Probable C1q glomerulopathy with
mesangial cell proliferation and occasional
crescent formation.

75. Second biopsy Case 3
6 yr old boy with C1q nephropathy diagnosed
by biopsy Dec 2001. Has been on cyclosporine
For ~2 yrs. Initial presentation – HTN, hematuria,
↑creat. For F/U biopsy.

82. IF
• IgG –Trivial to mild mesangial staining.
• IgA –Negative.
• IgM –Mild mesangial staining.
• C3 –Trivial to mild mesangial staining. Mild to
moderate vascular staining.
• C1q –Mild to moderate mesangial staining.
• Kappa –Mild to moderate mesangial staining.
• Lambda−Mild mesangial staining.
• Fibrinogen –Mild interstitial staining.
• Albumin – Negative.

83. IgG

84. IgM

85. C3

86. Clq

87. Kappa

88. Lambda

89. Fibrin

99. Diagnosis:
Renal Biopsy:C1q nephropathy, with
Mesangioproliferative and segmental
Sclerosing lesions.
(A)Chronic changes with estimated
20 – 30% glomerular loss and parenchymal
Scarring.
(B)Associated tubulointerstitial nephritis.
(C)Mild microvascular changes consistent
With cyclosporine nephrotoxicity.

101. Case 4
L native kidney. ARF creatinine = 280,
proteinuria +++,
Hb +++. Fine casts +++. ESR ↑, ANA +, RF
+, C3,
C4 Normal. No previous renal history.

111. IF
• IgG-Negative.
• IgA-Mild to moderate mesangial staining.
• IgM- Moderate vascular staining.
• C3-Moderate vascular staining – trivial to mild
punctate mesangial staining.
• C1q- Negative.
• Kappa- Negative.
• Lambda-Mild to moderate mesangial staining
• Fibrin-Mild to moderate interstitial staining.
• Albumin- Negative.

112. IgA

113. IgM

114. C3

115. Lambda

116. Fibrin

117. C3

123. Diagnosis:
Renal Biopsy:Diffuse proliferative
glomerulonephritis with features of
membranoproliferative
glomerulonephritis but with positive
staining for IgA in the mesangium.
Possible IgA nephropathy in the
diffuse proliferative form or
coincidence of two different
glomerular processes.

124. This 36 yo female, evaluated for persistent
microhematuria in the absence of
proteinuria, is a potential kidney donor to
her father. The recipient has ESRD on the
basis of diabetic nephropathy and pANCA
pauci-immune GN. Her mother had ESRD of
unknown cause and is now deceased. There
is no other family history of renal disease
among 5 siblings and her 3 children.
Serological testing was negative.
Case 5

125. Microscopic hematuria in potential
kidney donor.
Case 5

127. Atrophic and normal glomeru

130. Atrophic tubules

131. IF, TA, no interstitial inflammation

133. Lambda

134. C3 Splitting of L. densa

135. Kappa

136. Widening of subendothelial space and thin
of glomerular capillary loop basement me

137. Diagnosis:
Renal Biopsy:
Probable thin basement membrane
syndrome. Cannot completely
exclude hereditary nephritis.

138. 25 year old male, sent to Edmonton from Red
Deer with a serum
creatinine of ~400 and MRA suggestive of
RAS.
Angio was negative so a renal biopsy was
ordered. He has no significant past medical
history prior to being seen in Red Deer. While
admitted there, he was treated for malignant
HTN and his lab work up was unremarkable.
Case 6

139. Case 6
24 year old male with malignant hypertension
And renal failure (Cr 400) NYD.

141. e glomerular size with increase mes. matrix and cellu

142. glomerulus (25/32), IF, TA. and mononuclear cell infil

143. cinous intimal thickening of artery

145. Rare fibrin tactoids

146. IF
• IgG- negative
• IgA- strong mesangial staining
• IgM- mild mesangial staining
• C3- moderate mesangial staining, moderate vascular
staining
• C1q- negative
• Kappa- moderate mesangial staining
• Lambda- moderate mesangial staining
• Fibrin- mild to moderate interstitial staining
• Albumin- moderate hyaline droplet change in tubular
cytoplasm

147. IgA

148. IgM

149. C3

150. Kappa

151. Lambda

152. Fibrin

153. Albumin

154. Sclerosis, wrinkling and collapse of capillary loo

155. C3

156. Kappa
Parenchymal scarring

157. Lambda

158. Diagnosis:
Renal Biopsy: IgA nephropathy
with superimposed malignant
phase hypertension with
thrombotic microangiopathy and
extensive parenchymal atrophy
and scarring with widespread
glomerulosclerosis.

159. U03-13285
#015014502108
Ms RS, 41 yo female, lupus Dx 2000..alopecia, leukopenia/anemia,
arthralgias, vasculitis
CyP IV x 5 months then po x 1 months prior to referral (May 2003) because of
necrotizing vasculitis … stopped because of neutropenia
•Exam reveals
•BP 110/76
•patchy vitiligo, alopecia
•no active joints
•PMHx
–lupus as above
•Meds:
–prednisone
–Plaquenil,
•Labs initially:
•SCr 75, CrCl ~ 90
ml/min
•urine 2+ protein/ 2+
blood
•P:C ratio 135
mg/mmol
•24 hr protein 1.9 g
•Hgb 90, WBC 2.2
•C3/C4 low, anti
dsDNA high

160. U03-13285
#015014502108
Native Left Kidney.
LUPUS – now
proteinuria/hematuria. ?
Stage.

162. ening of Glom. capillary loops
mesangial hypercellularity

163. ncipient crescent

164. Double contours in silver stain

165. ubular hyaline casts

166. Mononuclear inflammatory cell infiltration

167. Tubular atrophy and interstitial fibrosis

168. IF
• IgG- Mild finely granular capillary loop staining.
• IgA- Negative
• IgM- Mild finely granular capillary loop staining.
• C3- Mild to moderate finely granular capillary loop
staining.
• C1q- Mild to moderate finely granular capillary loop
staining; moderate granular peritubular staining
• Kappa- Mild finely granular capillary loop staining.
• Lambda- Mild finely granular capillary loop staining.
• Fibrin- Negative
• Albumin- Negative

169. IgG

170. IgM

171. C3

172. Clq

173. Clq

174. Kappa

175. Lambda

176. Diagnosis:
Renal Biopsy:
Mixed membranous and proliferative
glomerulonephritis with features
suggesting SLE.
Low activity and low chronicity. No
glomeruli in material for EM.

177. Second biopsy
Native left kidney. Known SLE
previous renal bx 2003. Now ↑↑ SCr.
↑ Ds DNA Ab.
?Active nephritis.

179. glomeruli (8/42), monouclear inflammatory cells infi

181. creased lobulation of glomerulus

182. yaline thrombi

183. Epithelial crescen

185. ibrinoid change

186. ling and collapse of capillary loop, ? double contours

187. r atrophy and interstitial fibrosis

188. brin thrombi

189. IF
• IgG- moderate coarsely granular loop and mesangial staining;
moderate granular peritubular staining.
• IgA- negative
• IgM- mild to moderate granular capillary loop and mesangial
staining
• C3- mild to moderate granular peritubular staining; mild to
moderate vascular staining
• C1q- moderate granular peritubular staining; moderate granular
capillary loop and mesangial staining.
• Kappa- mild coarsely granular capillary loop staining.
• Lambda- mild to moderate coarsely granular capillary loop
staining.
• Fibrin- negative
• Albumin- negative

190. IgG

191. IgG, Peritibular

192. IgM

193. C3, vascular

194. C3, peritubular

195. Clq, mesangial

196. Clq, peritubular

197. Lambda

198. Kappa

199. IgM
Wrinkling of loop

200. C3
Intramembranous deposition

201. Kappa

202. Lambda
Tubuloreticular structur

205. tramembranous deposits

206. Subendothelial deposit

207. ial fibrosis and lymphocytic infiltration

208. Diagnosis:
Renal Biopsy: Diffuse proliferative
lupus nephritis with crescent
formation and extensive glomerular
sclerosis.
Moderate activity and moderate
chronicity.

209. Case 7
Ms RS, 41 yo female, lupus Dx 2000..alopecia, leukopenia/anemia,
arthralgias, vasculitis
CyP IV x 5 months then po x 1 months prior to referral because of necrotizing
vasculitis … stopped because of neutropenia
•Exam reveals
•BP 110/76
•patchy vitiligo, alopecia
•no active joints
•PMHx
–lupus as above
•Meds:
–prednisone
–Plaquenil,
•Labs initially:
•SCr 75, CrCl ~ 90
ml/min
•urine 2+ protein/ 2+
blood
•P:C ratio 135
mg/mmol
•24 hr protein 1.9 g
•Hgb 90, WBC 2.2
•C3/C4 low, anti
dsDNA high

210. Case 7
Native Left Kidney.
LUPUS – now
proteinuria/hematuria. ?
Stage.

212. ening of Glom. capillary loops
mesangial hypercellularity

213. ncipient crescent

214. Double contours in silver stain

215. ubular hyaline casts

216. Mononuclear inflammatory cell infiltration

217. Tubular atrophy and interstitial fibrosis

218. IF
• IgG- Mild finely granular capillary loop staining.
• IgA- Negative
• IgM- Mild finely granular capillary loop staining.
• C3- Mild to moderate finely granular capillary loop
staining.
• C1q- Mild to moderate finely granular capillary loop
staining; moderate granular peritubular staining
• Kappa- Mild finely granular capillary loop staining.
• Lambda- Mild finely granular capillary loop staining.
• Fibrin- Negative
• Albumin- Negative

219. IgG

220. IgM

221. C3

222. Clq

223. Clq

224. Kappa

225. Lambda

226. Diagnosis:
Renal Biopsy:
Mixed membranous and proliferative
glomerulonephritis with features
suggesting SLE.
Low activity and low chronicity. No
glomeruli in material for EM.

227. Case 8 second biopsy
Native left kidney. Known SLE
previous renal bx 2003. Now ↑↑ SCr.
↑ Ds DNA Ab.
?Active nephritis.

229. glomeruli (8/42), monouclear inflammatory cells infi

231. creased lobulation of glomerulus

232. yaline thrombi

233. Epithelial crescen

235. ibrinoid change

236. ling and collapse of capillary loop, ? double contours

237. r atrophy and interstitial fibrosis

238. brin thrombi

239. IF
• IgG- moderate coarsely granular loop and mesangial staining;
moderate granular peritubular staining.
• IgA- negative
• IgM- mild to moderate granular capillary loop and mesangial
staining
• C3- mild to moderate granular peritubular staining; mild to
moderate vascular staining
• C1q- moderate granular peritubular staining; moderate granular
capillary loop and mesangial staining.
• Kappa- mild coarsely granular capillary loop staining.
• Lambda- mild to moderate coarsely granular capillary loop
staining.
• Fibrin- negative
• Albumin- negative

240. IgG

241. IgG, Peritibular

242. IgM

243. C3, vascular

244. C3, peritubular

245. Clq, mesangial

246. Clq, peritubular

247. Lambda

248. Kappa

249. IgM
Wrinkling of loop

250. C3
Intramembranous deposition

251. Kappa

252. Lambda
Tubuloreticular structur

255. tramembranous deposits

256. Subendothelial deposit

257. ial fibrosis and lymphocytic infiltration

258. Diagnosis:
Renal Biopsy: Diffuse proliferative
lupus nephritis with crescent
formation and extensive glomerular
sclerosis.
Moderate activity and moderate
chronicity.

259. ID: 77 year old female
RFR: nephrotic syndrome
HPI: Patient has a 7 month history of peripheral edema, mostly in lower
extremities and hands. Noted to have rapid onset of ~ 1 week. No further
urinary symptoms or hematuria.
No constitutional symptoms or vasculitis symptoms. One prior blood
transfusion 20 years ago; no history of hepatitis. No history of diabetes.
Hypertension diagnosed 2 months prior to referral. On Diclofenac
irregularly: 3-4 pills per month although higher usage in remote past.
Otherwise healthy. Other meds: Ramipril, HCTZ, Lipitor, Lakota,
multivitamin, Siberian ginseng, cayenne pepper.
Exam: Looked well. bp: 135/65. bilateral edema in lower extremities to
knees and edema of hands. otherwise unremarkable.
Labs: Cr 79, urea 5.6 albumin 22 total protein 49 urinalysis: 3+ protein,
3+ Hb Pr:Cr ratio 915 mg/mol
SPEP, UPEP: no free light chains; C3 C4 normal; ANCA, Hep B, Hep C
neg.