This document provides an overview of kidney biopsy procedures and pathological examination of biopsy samples. It discusses indications for kidney biopsy, techniques for performing native and transplant biopsies, post-biopsy care, adequacy of samples, and transportation of samples. It also describes examination of samples including staining, microscopy, immunohistochemistry, and interpretation. Key abnormalities that can be seen including glomerular, vascular, tubular, and interstitial lesions are summarized.

1. Dr.C.Lingasamy
3/11/17

2.  Indroduction
 Indications
 Techniques
 Post-Kidney biopsy care
 Adequacy of tissue sampling
 Clinical information and Transportation
 Sectioning and Fixation

3.  Staining and Light microscopy,IF,IHC,ISH
 Tissue examination and Interpretation
 Abnormalities in Glomerular capsule
 Cellular proliferation
 Vascular lesions
 Tubulo intertitial lesions
 Intertitial lesions
 Transplant kidney biopsy

7.  one of the major events in the history of
nephrology. After unpublished attempts by
Alwall in Sweden in 1944.
 Brun and Iversen of Copenhagen in 1951were
the first to publish aspiration biopsy with
patients in the sitting position.
 Kark and Muehrcke in 1954 who performed
the first kidney biopsy in the prone position
using Vim–Silverman needle

8.  As renal transplant is significantly different
from native kidney biopsy.

9.  Unexplained acute or rapidly progressive
renal failure
• Nephrotic syndrome and significant
non-nephrotic proteinuria.
• Persistent glomerular hematuria
• Systemic diseases with renal involvement
• Renal allograft dysfunction.

10.  Absolute
1. Small kidneys
2. Abnormal coagulopathy
3. Uncontrolled hypertension
 Relative
1. Solitary kidney
2. Uncooperative patient
3. Unable to lie flat on bed

11.  Position of the patient
prone position.
Lower pole –Left- to reduce the risk of
inadvertent injury to a major vessel.
 Percutaneous ultrasound-guided kidney
biopsy was performed in SALP POSITION in
obese patients with breathing difficulty

12.  Vim–Silverman needle
 Tru-Cut
 automatic spring-loaded biopsy guns
 ultrasound guided 18-gauge (full-core)
spring-loaded biopsy gun
 Transjugular kidney biopsy

15.  Biopsy performed after ultrasound marking
or under real-time, ultrasound-(US)
guidance.
-Failure rate of 0-3%, complications in 0-7%
with major complications in ≤3% of patients.
-The need for surgical interventions ranged
from 0 to 0.8%.
 CT-guided approach -employed in high-risk
and obese individuals

17.  Laparoscopic kidney biopsy- it allows positive
identification of kidneys for macroscopic
diagnosis.
 Indications-1.Failed percutaneous biopsy
2. Chronic anticoagulation state/coagulopathy
3. Morbid obesity
4. Solitary kidney
5. Multiple bilateral kidney cysts
6. Kidney artery aneurysm
7. Uncontrolled hypertension

18.  under G/A wit- lateral decubitus position,
-10-mm laparoscopic port-above the iliac crest in
posterior axillary line,
-5-mm port is placed at the same level in the
anterior axillary line,
-lower pole of kidney is exposed after minimal
blunt retroperitoneal dissection,
-Laparoscopic cup biopsy forceps are used to
take multiple superficial cortical biopsies,
-The biopsy site can be fulgrated with argon
beam coagulator and a sheet of oxidized
cellulose can be applied there upon.

20. 1. Outdoor basis
2. Under vision
3. Wound infection is less compared to that in
open kidney biopsy
4. Adequate homeostasis achieved
5. Safe and reliable
6. If required, prompt conversion to open
procedure can be made.
 Disadvantages as against closed percutaneous
biopsy
1. Costly
2. Requires general anesthesia
3. More invasive than closed percutaneous biopsy.

21. - Right side - direct access to IVC.
-The sheath is then advanced over a stiff guide wire
into the IVC under fluoroscopic guidance,
-The kidney vein is selectively catheterized using a 4-F
or 5-F catheter introduced through the sheath.
-The sheath is then advanced over the catheter into
the kidney vein and an optimal peripheral position
located with the aid of contrast enhancement.
-Biopsy needle is then inserted and tissue sample is
obtained with the aid of spring-loaded gun.
-contrast can be injected to identify capsular
perforation, and embolization coils may be placed at
the discretion of the operator

22.  advantages:
• Safer as needle passes into vein and away
from major vessels.
• Capsular perforation managed with elective
coil embolization.
Disadvantages:
• Arterio-calyceal bleed.

23.  Vitals
 Bed rest
 Routine post-biopsy ultrasound is not
recommended.
 common complications are local pain, minor
bleeding in urinary tract, perinephric
hematoma, arteriovenous fistula.

24.  Sample size – two cylinders with a minimal
length of 1 cm and a diameter 1.2 mm .
• Needle gauge: 14-16 gauge (G).
• Number of glomeruli for adequate diagnosis:
• For glomerular lesions: 5.
• For tubulointerstitial lesions: 6-10.
• For transplant kidney: 7.

25.  Adequate clinical information.
 Specimen handle with gentle,
 NS use to wash the sample,
 Dissecting microscope or LM

26. Renal biopsy seen with dissecting
microscope
a) Renal cortex: glomeruli, recognized as
round red areas
(wet preparation, x 10)
b) Renal medulla: reddish vasculature is
present but no glomeruli seen
(wet preparation x 10)

27.  LM:- These fixatives include 10% formalin,
paraformaldehyde, or less commonly used
alcoholic Bouin’s or Zenker’s.
 IF:-Tissue should include small piece of cortex
- 3 to 4 mm. placed in Phosphate Buffer Saline
and kept in frozen state,
 Transport media : Michel’s media
 EM:- 1-mm piece of cortex; glutaraldehyde
(Paraffin section can be used)

30. Hematoxylin and Eosin
PRIMARY REVIEW
Basement membrane
collagen fibers
Jone’s silver methenaminePeriodic acid Schiff
Gomori’s trichrome Congo red
STAINS USED FOR RENAL HISTOLOGY
Basement membrane
Congo red under polarizer

31.  unfixed, frozen sections.
 Tissue can be transported to the laboratory
fresh on saline-soaked gauze or in Michel’s
fixative.
 2-4 μm in a cryostat
 Fluorescein-labeled antibodies -examined
immunoglobulins - primarily IgG,IgM, and IgA,
- complement components –primarily C3, C1q,
C4
- fibrin, and kappa and lambda light chains.

32.  EM may be fixed in 2-3% glutaraldehyde or
1-4% paraformaldehyde or buffered formalin.
 Rapid placement of the sample
 Toluidine blue-stained 1-μm thick sections
Uses • Hematuria, especially microscopic,
with or without proteinuria.
• family history of renal disease.
• symptomatic proteinuria, with normal
renal excretory function.

33.  IHC detects specific proteins by mono-or
polyclonal antibodies raised against that
protein in biopsy.
-Hepatitis B virus and SV40 antigen for BK
Polyoma virus infection.

34. Light chain-associated diseases
AL amyloid
Monoclonal immunoglobulin deposition disease
Light chain cast nephropathy
IgA nephropathy/Henoch–Shonlein purpura
IgM nephropathy
C1q nephropathy
Antiglomerular basement membrane disease
Humoral (C4d) transplant rejection
Fibronectin glomerulopathy

35.  Uses labeled cDNA or RNA probes.
 It localizes specific DNA/RNA sequence
quantitated using autoradiography or
fluorescence microscopy.
 1.BK virus.
 2. EB virus probes in the diagnosis of PTLD.
 3. Pathogenic cytokines - PDGF,EGF.

36. GLOMERULI TUBULES
ARTERIOLES INTERSTITIUM

37.  Diffuse change: Changes in all glomeruli.
• Focal changes: Changes in few glomeruli
only.
• Global changes: Whole glomerulus .
• Segmental changes: some part of glomerulus

38. DIFFUSENORMAL
MAJORITY (>50%)
GLOMERULI ARE INVOLVED IN
DISEASE PROCESS
FOCAL
MINORITY OR LESS THAN 50%
GLOMERULI ARE INVOLVED IN
DISEASE PROCESS

39. NORMAL
GLOMERULUS
Bowmans capsule
Capillary tuft
Part of a glomerulus is involved
but usually less than 50%
JMS, X 400

40. NORMAL
GLOMERULUS
Bowmans capsule
Capillary tuft
Entire Glomerulus is involved
PAS, X 400

42.  Glomerular capsule is made up of outer BM
and inner epithelium.
 Between glomerular capsule and visceral
epithelial cell layer is capsular space.
 Abnormalities can be in basement
membrane, epithelium and capsular space.

45.  3 types of cellular elements in glomerulus
 Endothelialcells -small nucleus,dense
chromatin, and very little cytoplasm.
 Epithelial cells - large nucleus,chromatin is
loose and indistinct, and cytoplasm is
copious.
 Mesangial cell resembles endothelial cells,
Mesangial cell is PAS positive and nucleus is
darkest compared all.
 Endothelial 45%, mesangial25%, and
epithelial 30% .

46.  Crescents - accumulation of cells and
extracellular material in the urinary space.
 Mesangial cells -migrating between
endothelial cell and BM, causing capillary
wall thickening in 2 layers of ECM.
 visceral - “effacement of foot processes” .

47. INTRACAPILLARY EXTRACAPILLARY
ENDOTHELIAL
CELLS
(35%)
MESANGIAL
CELLS
(25%)
VISCERAL
(30%)
PARIETAL
EPITHELIAL
CELLS (10%)
• Total number of cells in glomerulus : 200 + 30
• In a 2 – 3 µm thick section : 50 + 10
• Proliferative capacity : Mesangial > Parietal > Endothelial > Visceral

48. Extracapillary proliferation of more than two cell layers
occupying 25% or more of glomerular tuft .
Parietal Epithelial
cell proliferation
CELLULAR
CRESCENT
FIBROUS
CRESCENT
FIBRO-CELLULAR
CELLULAR
CRESCENT
HE, X200

49. PAS, X 400JSM, X 400JSM, X 1000
WRINKLING
DOUBLE
CONTOURING
THICKENING WITH HOLES
AND SPIKES

50. Endocapillary
Proliferation
Proliferation that
occurs in the tuft
Capillary loop Capillary loop with
endothelial cells
Cells proliferating
into the mesangial
space
Intraluminal : In the
capillary lumen,
endothelial cell
swelling, hyaline
thrombi, fibrin
thrombi, cells
Glomerular BM
Podocyte
Endothelial
cell
HE, X400

51. INTRACAPILLARY
(WITHIN GLOMERULAR TUFT)
EXTRACAPILLARY
ENDOCAPILLARY
(With closure of
glomerular capillaries)
MESANGIAL
DIFFUSE FOCAL
• PIGN
• MPGN
• FOCAL
GN
• IgA
Nephropathy
• Class II Lupus
nephropathy
• Resolving PIGN
IF
POSITIVE NEGATIVE
LINEAR
PATTERN
ANTI-GBM • SLE
• IMMUNE
COMPLEX
GRANULAR
PATTERN
NEGATIVE POSITIVE
ANCA
• Idiopathic
• Vasculitis
• Vasculitis

53.  Three layers
 Tunica intima – endothelial layer and connective tissue
 Tunica media – smooth muscle layer
 Tunica externa – connective tissue sheath around the vessel

54. BLOOD VESSELS
Large elastic
arteries
Medium-sized
muscular arteries
Small arteries
and arterioles
Media is abundant in
elastic fibres
allowing it to expand
with systole and
recoil during
diastole, thereby
propelling blood
forward.
Diameter : 1 – 2 cm
Media is abundant in
smooth muscle cells that
vasoconstrict or vasodilate,
thereby controlling lumen
diameter and regional
blood flow
Diameter :
0.1 – 0.9 cm
Absence of
external elastic
lamina and poorly
developed internal
elastic lamina
controlling systemic
blood pressure as
well as regional blood
flow.

55.  Afferent arteriole is made up of smooth
muscle -lined by endothelium- continuous
with glomerulus.
 Efferent arteriole is smaller than afferent
arteriole in outer cortex.

56.  The major lesions affecting renal vasculature
• Thrombosis
• Fibrin deposition in arteries, arterioles,
glomerular capillaries;
• Inflammation and necrosis of vascular walls;
an Arteriosclerosis.

57.  Fibrinoid change- Homogenous, refractile,
eosinophilic,often granular with poorly
defined edge and is PAS negative.
 Hyaline change-PAS positive, acellular,
homogenous,refractile, less eosinophilic
boundaries are defined.

60. MINIMAL INTERSTITIUM
BACK TO BACK ARRANGED
TUBULES
INCONSPICUOUS TUBULAR
LUMINA
SMALL CALIBER BLOOD
VESSEL
MEDIUM CALIBER BLOOD
VESSEL

61. • PCT: PAS +ve
• Brush borders ++
TUBULES
DISTAL CONVOLUTED
TUBULES
PROXIMAL CONVOLUTED
TUBULES
• DCT: PAS Negative
• Brush borders: Absent
Normal arrangement: back to back with barely visible lumina
PAS, X 200 HE, X 200

62. • Atrophy (normally absent)
• Regeneration
• Microcalcification
TUBULES
FEATURES TO STUDY
Basement membranes
Degeneration (size of lumen, lining cells)

63.  ACUTE TUBULAR
INJURY:
 Loss of brush border on
PAS stain
 Thin cytoplasm
 Simplification of tubular
epithelium with mild
TBM thickening.
PAS, X 200

64. WBCs IN THE TUBULAR LUMINA ( Stain: PAS, X 400)

65. PREDOMINANTLY NON-INFLAMMATORY (TUBULAR) LESIONS
Tubular epithelium - Tubular casts Tubular atrophy/ interstitial fibrosis
-Degeneration/ regeneration Myeloma cast (chronic tubulo-interstitial
)
-Ischemia nephropathy
-Toxic - Myo/hemoglobinuria
-Pigments - End stage kidney
-Lipofuchsin - HIV- associated Extensive intratubular Idiopathic
-Hemosiderin nephropathy - Interstitial crystalline - Non-steroidal anti-
-Myo/ hemoglobinuria deposits inflammatory (or other)
-Melanuria - Oxalate nephropathy - Nephropathy and
-Bile nephrosis - Urate nephropathy papillary necrosis
-Inclusions - Nephrocalcinosis
- End stage kidney
-Hyaline droplet degeneration (any etiology)
-Vacuoles (osmotic nephropathy) - Nephrosclerosis
(Hypopotassemia, glycogen, lipid) - Focal scar
-Metabolic diseases - Balkan endemic nephropat
-Lead poisoning - Exposure to heavy metals

66. ► Normally minimal
► Density compared to tubular
basement membrane
► No infiltration/ oedema/
fibrosis
INTERSTITIUM
HE, X 200 GT, X 200
JSM, X 200

67. EOSINOPHILS IN THE INTERSTITIUM : DRUGS, VASCULITIS (CHRUG STRAUSS
SYNDROME) ( Stain: HE, X 400)

68. Predominantly cellular infiltrate (interstitial)
Malignant Benign tubulo-interstitial nephritis
- Lymphoma
- Leukemia
Type of Neutrophilic Lymphoplasmacytic Eosinophlis (or mixed) Granulomatous/ foamy
Inflammatory - Infectious (acute) - Chronic tubulo- Drug induced tubulo- macrophages
infiltrate pyelonephritis interstitial nephritis interstitial nephritis - Tuberculosis
- Drug induced (any etiology) - Vasculitis - Sarcoidosis
- Idiopathic - Acute SLE - SLE - Drug-induced
- HIV associated - Tubulo-interstitial
nephropathy nephritis
- Drug induced - Xanthogranulomatous PN
- Infectious - Idiopathic
- Anti-tubular basement
membrane disease
- Idiopathic

69.  An abrupt (within 48 h) reduction in kidney
function currently defined as :
 An absolute increase in serum creatinine of ≥0.3 mg/dL
(≥26.4 µmol/L),
 percentage increase in serum creatinine of ≥ 50%
(1.5-fold from baseline), or
 reduction in urine output (documented oliguria of less
than 0.5 mL/kg/h for more than 6 h).

70. GRAFT BIOPSY
INDICATED
BIOPSY
Prompted by change
in patient’s clinical
condition &/or Lab
parameters.
PROTOCOL
BIOPSY
Bx at predefined
intervals after
transplant, regardless
RFT

71. • ≥ 10 GLOMERULI AND 2 ARTERIES
ADEQUATE
• 7 GLOMERULI AND ONE ARTERYMARGINAL
• ≤ 7 GLOMERULI AND NO
ARTERY
UNSATISFACTORY
•“ONE ARTERY – ENDARTERITIS” OR
“GLOMERULUS WITH MEMBRANOUS
LESION”
ADEQUATE

72. ACUTE CHANGES
CHRONIC CHANGES
TUBULITIS
VASCULITIS
GLOMERULITIS
INTERSTITIAL
INFLAMMATION
TRANSPLANT
GLOMERULOPATHY
TUBULAR ATROPHY
INTERSTITIAL FIBROSIS
ARTERIAL HYALINOSIS
ARTERIAL FIBROINTIMAL
THICKENING

73. NORMAL
GLOMERULUS
GLOMERULITI
S
g1 : <25 % of glomeruli g2 :25 – 75 % of glomeruli g3: >75 % of glomeruli

74. 1 – 4 LYMPHOCYTES PER TUBULAR CROSS
SECTIONAL AREA
5 – 10 LYMPHOCYTES PER TUBULAR
CROSS
SECTIONAL AREA
> 10 LYMPHOCYTES PER TUBULAR
CROSS SECTIONAL AREA
t
1
t
3
t2
t
1
t
3

75. t
1
t
2
t
3
PAS, X
400

76. SUBINTIMAL LYMPHOCYTES
OCCLUDING LESS THAN 25% OF THE
LUMEN
(Minimum 1 cell, 1 artery)
SUBINTIMAL LYMPHOCYTES
OCCLUDING > THAN 25% OF THE LUMEN
(Lesion in more than 1 artery)
TRANSMURAL INFLAMMATION OR
FIBRINOID NECROSIS
V1
V2
V3

77. V1 V2 V3
Lymphocytic infiltration beneath the endothelium, from arteritis
with inflammation in the media and/ or with fibrinoid necrosis of
the vessel wall.
PAS, X

78. i0
i1 i2 i3
10 -25% 26 – 50% >50 %
Mononuclear Inflammation In Non Fibrotic Areas
PAS, X
100
HE, X 100

79. Phases
(Time since
transplantation)
Phase I
(< 4 weeks)
Phase II
(1 month – 1yr)
Phase III
(>1year)
Nature of
infections
Technical,
nosocomial,
related to
lines,
catheters,
tubes
Reactivated
viruses,
Opportunistic
infections
Continued risk of
viral and
opportunistic
infections
Viral oncogenesis
Organisms
MRSA, Candida,
E.coli
CMV, EBV, HSV,
VZV, HBV, PCP,
Nocardia,
tuberculosis,
toxoplasma,
candida,
aspergillus,
zygomycetes,
strongyloides
CMV, EBV, PCP,
BKV, Nocardia,
tuberculosis,
toxoplasma,
aspergillus,
zygomycetes,
strongyloides
CMV :
Chorioretinitis
EBV : PTLD
HHV8: Kaposi
sarcoma
HPV : Cervical,
skin cancer
HBV, HCV :
Hepatocellular

80.  S. K. Agarwal, S. Sethi, A. K. Dinda. Basics of
kidney biopsy: A nephrologist’s perspective
 Patrick D. Walker, MD. The Renal Biopsy
 Patrick D Walker, Tito Cavallo, Stephen M
Bonsib. Practice guidelines for the renal
biopsy.
 Robbins Robbins & Cotran Pathologic Basis of
Disease 9E.

81. THANK YOU