How to Interpret a Kidney Biopsy

Federal University of Bahia

A simple and systematic guide to kidney biopsy interpretation

Health & Medicine

Sheffield Kidney Institute
Preston Fifth Renal Biopsy Course
2016
ABC:
How to Interpret a Kidney Biopsy
Professor Meguid El Nahas, PhD, FRCP
Chairman, Global Kidney Academy
Sheffield, UK

Sheffield Kidney Institute
I cant be bothered to
look at the Biopsy!!!!
I’ll will wait to read
Pathology report.!!!!
The Incomplete Nephrologist

Sheffield Kidney Institute
Renal Histological Diagnosis
LM
IF
EM

Sheffield Kidney Institute
Masson’s trichrome
Silver stain
Congo Red
PAS
Examples of stainings
H&E

Sheffield Kidney Institute
Immunofluorescence : some aspects
IgGIgG

Sheffield Kidney Institute
AL
Immunofluorescence
IgG

Sheffield Kidney Institute
The Glomerulus
• Representative number of glomeruli
• Cellularity
• Infiltration
• Proliferation/Crescents
• Mesangium
• Cellularity
• Matrix Expansion
• Hyalinosis/Sclerosis/Adhesions
• Capsular adhesions

Sheffield Kidney Institute
Glomerular Intrinsic Proliferation

Sheffield Kidney Institute
Glomerular Extrinsic Proliferation
Endo-Capillary
Extra-Capillary

Sheffield Kidney Institute
Proliferation
=
Intrinsic
Extrinsic

Sheffield Kidney Institute
GBM Thickening

Sheffield Kidney Institute
GBM
Podocytopathy
=
PROTEINURIA
(not proteinurea…!!!)

Sheffield Kidney Institute
Glomerular Intrinsic Proliferation
+
GBM Thickening

Sheffield Kidney Institute
Proliferation + GBM Disruption
MCGN
MN + Mes Proliferation
DN + Mes Proliferation

Sheffield Kidney Institute
+
Clinical Manifestation

Sheffield Kidney Institute
Renal Functional Decline
Glomerular Destruction
Glomerular Obstruction

Sheffield Kidney Institute
Glomerular Destruction
Necrosis

Sheffield Kidney Institute
Glomerular Destruction
Hyalinosis

Sheffield Kidney Institute
Glomerular Destruction
Sclerosis (Segmental)

Sheffield Kidney Institute
Glomerular Destruction
Sclerosis (Global)

Sheffield Kidney Institute
Glomerular Obstruction
Endo-capillary

Sheffield Kidney Institute
Glomerular Obstruction
Extra-capillary

Sheffield Kidney Institute
Renal Tubules
• Tubular structure
• Atrophy
• Denuded TBM
• Mitotic figures
• Abnormal Nuclei
• Tubular inflammatory infiltration

Sheffield Kidney Institute
Renal Interstitium
Inflammation
Fibrosis

Sheffield Kidney Institute
Renal Histopathology
• Examine the Glomeruli
• Examine the Tubules
• Examine the Interstitium
• Examine the Vessels

Sheffield Kidney Institute
Clinico-Pathological Correlations

Sheffield Kidney Institute
Case 1
Hematuria: YES (micro/non-visible)
Proteinuria: NO
Renal Function: NORMAL
What is the most Likely Histology?

Sheffield Kidney Institute
Histological Diagnosis
Hematuria: ++, Proteinuria: -, Renal Function: N
Glomerular or Interstitial?
Mesangial or Podocyte?
GBM Normal or Disrupted?
Glomerular Proliferation?
Glomerular Obstruction ?

Sheffield Kidney Institute
Histological Diagnosis
Hematuria: ++, Proteinuria: -, Renal Function: N
Glomerular : YES
Mesangial
GBM Disrupted? NO
Glomerular Proliferation: YES
Glomerular Obstruction: NO

Sheffield Kidney Institute
Mesangial Disruption = Hematuria

Sheffield Kidney Institute
Case 2
Hematuria: -, Proteinuria: +++, Renal Function: N
Glomerular or Interstitial?
Mesangial or Podocyte?
GBM Normal or Disrupted?
Glomerular Proliferation?
Glomerular Obstruction?

Sheffield Kidney Institute
Case 2
Hematuria: -, Proteinuria: +++, Renal Function: N
Glomerular: YES
GBM Disrupted: YES
Glomerular Proliferation? NO
Glomerular Obstruction? NO

Sheffield Kidney Institute
Podocyte Disruption = Proteinuria

Sheffield Kidney Institute
Case 3
Hematuria: ++, Proteinuria: +++, Renal Function: N
Glomerular or Interstitial?
Mesangial or Podocyte?
GBM Normal or Disrupted?
Glomerular Proliferation?
Glomerular Obstruction?

Sheffield Kidney Institute
Case 3
Hematuria: ++, Proteinuria: +++, Renal Function: N
Glomerular or Interstitial
Mesangial & Podocyte
GBM Normal or Disrupted
Glomerular Proliferation? NO
Glomerular Obstruction? NO

Sheffield Kidney Institute
Proliferation + GBM Disruption

Sheffield Kidney Institute
RAPID
DECLINE
=
Decreased
Filtration
Space
+ +

Sheffield Kidney Institute
Glomerular Destruction
Necrosis
GFR

Sheffield Kidney Institute
Glomerular Destruction
Sclerosis
GFR

Sheffield Kidney Institute
Glomerular Obstruction
Endo-Capillary
GFR

Sheffield Kidney Institute
Glomerular Obstruction
Extra-Capillary
GFR

Sheffield Kidney Institute
Renal
Function:
SLOW
DECLINE
+ +

Sheffield Kidney Institute
Renal Functional Decline
Glomerular Obstruction
Glomerular Destruction

Sheffield Kidney Institute
Case 4
Hematuria: -, Proteinuria: +, Renal Function: N
Glomerular or Tubulo-Interstitial?
Mesangial or Podocyte?
GBM Normal or Disrupted?
Glomerular Proliferation?
Glomerular Obstruction?

Sheffield Kidney Institute
Histological Diagnosis
Hematuria: -, Proteinuria: +, Renal Function: Normal
Glomerular or Tubulo-Interstitial
Tubular Destruction?
Tubular Obstruction: ?

Sheffield Kidney Institute
Renal Functional Decline
Tubular Destruction
Tubular Obstruction

Sheffield Kidney Institute
Tubular Atrophy

Sheffield Kidney Institute
Renal Functional Decline
Tubular Obstruction
Tubular Destruction

Sheffield Kidney Institute
78 year old with Atherosclerosis

Sheffield Kidney Institute
78 year old with Atherosclerosis
Proteinuria
Low GFR
Hypertension

Sheffield Kidney Institute
Be a Complete
Nephrologist:
Think Clinico-
Pathological
Correlations

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