Renal biopsy

Renal biopsy
• A renal biopsy is a
procedure to
remove a small
piece of kidney
tissue that can be
examined under a
microscope for
signs of damage
or disease fine
use needle
⑨
• Percutaneous
V

• Laparoscopic
 Why it's done
not for
diagnose of
cancer

• Diagnose a kidney problem that can't otherwise be

identified
• Help develop treatment plans based on the kidney's
condition
• Determine how quickly kidney disease is progressing
• Determine the extent of damage from kidney disease
or another disease
• Evaluate how well treatment for kidney disease is
working for rejectionreason
X
• Monitor the health of a transplanted kidney or find out
why a transplanted kidney isn't working properly
• Glomerular Diseases
• Diseases Affecting Tubules And Interstitium
• Vascular Diseases of the Kidney
• ……….
 Preparation of renal biopsy
• sent fresh to the laboratory
• sample size
– Length : 1-2 cores each about
10mm ~/cmxl-2 piece

– Diameter: 1-1.5mm
↑
– 8-15 glomeruli (<10 glomerulus) EP glomeruli
glomenclus
<-

UPEFHFERTIAFET
– Exclusion of focal disease is medulla
↑

difficult if sample size is small

– Determination of disease Renal biopsy specimens as seen with
severity a dissecting microscope
Jonathan J. Hogan et al. CJASN doi:10.2215/CJN.05750515

➢percentage of glomeruli ©2015 by American Society of Nephrology

involvement
 Preparation of renal biopsy
• urgent graft biopsies requiring quick paraffin
processing should be processed by the rapid
paraffin processing program
• Frozen HE (& PAS) sections should be ready on
the day of biopsy received
 Preparation of renal biopsy
• Identify the presence of glomeruli with a
dissecting microscope
do not contaminate the section w/fixative

• Avoid
➢Drying – small amount of normal saline can be used
to keep specimen moist
➢Crush artifact – use wooden sticks / fine forceps
– use sharp razor blade
➢Handle tissue with fixative contaminated
instruments
• Divide specimen under dissecting microscope
 Preparation of renal biopsy
Specimen from renal cortex for
• Electron Microscopy (TEM)
➢ Fix with 3% glutaraldehyde 11-2mmulatleast 1 glomenlus)

• Immunofluorescence (IF)
➢ Frozen block
• Light Microscopy (LM)
➢ Fix in 10% NBF
➢ Wrap with wrapping paper wetted with NBF
 Tissue Examination
Specimen confirmed with presence of glomeruli
• Light Microscopy (LM) 5
collagen4
&
virus

➢HE, PAS, T, PASM, CR, IHC (C4d, BKV)

• Immunofluorescence (IF)
➢IgA, IgG, IgM, C3, C1q, Fibrinogen, κ- and λ-light
chains
➢C4, AHG
• Electron Microscopy (TEM)
t
identify ultrastructure
 Priority of Tissue Sampling
– sufficient renal cortex:
➢at least 5 glomeruli for frozen block (5mm)
➢2 glomeruli for EM (2mm)
➢the rest for paraffin
– little renal cortex:
➢1 to 2 glomeruli for frozen block
➢1 glomerulus for EM
➢the rest for paraffin
 Priority of Tissue Sampling
• scanty renal cortex:
➢priority should be given to IF and EM change Et minimal
some
disease can
only diagnose by e.g.

➢Minimal Change: EM > IF > LM and

I

➢IgA Nephropathy and Nephritis: IF > LM > EM

 Priority of Tissue Sampling
- graft biopsies
frozen block can be converted to paraffin
block or vice versa

• Obtained with finer needles with less tissue

• IF and EM studies should be performed as
usual on proteinuric graft biopsies
• For dysfunctional graft kidney
➢diagnosis is mainly between acute rejection /
arteriole constriction of
e.g.kidney
drug toxicity / acute tubular necrosis
from immunosuppressive drug after transplant

➢IF studies and EM study are rarely useful

 No glomerulus is present
transplant case:special stand IFis necessary
↳ to
diagnose tabular
necrosis

• Special Stains & IF are generally not necessary

• Make sure it is not tumor bx
necessary
• IF for diagnosis anti-tubular basement
X

membrane (TBM) disease

 No glomerulus is present
• Diagnosis in renal allograft
➢C4d stain: antibody-mediated rejection
➢drug toxicities: non rejection-associated injuries
and complications
• Diagnosis for infection & vasculitis
• Consult pathologist when in doubt
Light Microscopy (LM)
J Clin Invest DOI: 10.1172/JCI57935
 /ADDIEAM E
demonstrate glomerular basementmembrane
membranes
(not tubular basement
tubular by PASM
basement glomerular
membranes capillary wall
mesangial
cells

Normal glomerulus

https://www.uptodate.com/contents/image?imageKey=NEPH%2F57841~NEPH%2F74698~NEPH%2F55226~NEPH%2F69629~NEPH%2F6
2937~NEPH%2F69348&topicKey=NEPH%2F3050&source=see_link
 HE stain
• Routine diagnostic evaluation
• provides a first impression of the composition
of the tissue
➢ renal cortex vs medulla, number of glomeruli,
cellular infiltration, etc.
• Overview of any pathological changes
cut thinner (2 mm) to demonstrate GBM
↳ sufficient
if 4 rm GBM color X

focal segmental necrosis:diagnose by cutting diff. Iv. of

kidney
LETED areaJIAE stain HE)
 Patterns of glomerular lesions
• The first step in the evaluation of the
glomerular alterations is to determine the
extension of the affectation.
• Glomerular changes can be
– focal (only in some glomeruli)
– diffuse (in all or almost all the glomeruli)
– segmental (only a part of the glomerulus)
– global (the entire glomerulus)
The same glomerulus with chronic membranous GN, stained with both H&E (A) and PAS (B). Note the
relative thickness of the membranes. Why does the capillary wall appear much thinner on the PAS stained
section than on the H&E? glomerular structure:podocyte, GBM, epithelium
immune
deposit HE stain all components
Glomerular Capillary Wall Thickening on H&E – A Case of Membranous GN
* PAS only stain GBM but not others (American Journal of Kidney Diseases Blog 2017)
 Special stains
• Demonstrate different pathological features
that have different staining properties
• PAS
➢Show details of glomerular cells, mesangial matrix
➢Demonstrate changes in GBM – thickening,
irregularities
➢Detect alterations of the vessels particularly
arterial hyalinosis & fibrinoid necrosis in vessels
I fibrin
(protein deposit)
Diffuse Mesangial Sclerosis
nephrotic syndrome

thickened GBM

↓
⑨

vamolated >
podocytes
(stained by PAS

PAS stain

Stephen M. Bonsib. Atlas of Medical Renal Pathology. 2013th Edition. Springer Science & Business Media.
 Focal Segmental
Glomerulosclerosis (FSGS)

->
hyaline

PAS stain
↑ necrosis only part of glomerulus

Stephen M. Bonsib. Atlas of Medical Renal Pathology. 2013th Edition. Springer Science & Business Media.
 Special stains
For renalbiopsy case:
a counterstain light green
directly immerse in
↓ after differentiation
• Masson Trichrome
↳ do not check mic

➢Evaluate the extend of fibrosis in glomerulus or

tubular interstitium
➢Demonstrate protein deposition
 Diffuse proliferative lupus
glomerulonephritis, class IV

-
sub-endothelial
deposition

Masson Trichrome stain

Stephen M. Bonsib. Atlas of Medical Renal Pathology. 2013th Edition. Springer Science & Business Media.
 Special stains
• PASM
➢Demonstrate changes in GBM – double contour,
spikes
• Others
➢CR, Fe, VK
 thrombosis
kidney damaged by
Malignant hypertension, repair mechanismcellseparatetosee
↳

chronic lesion double contourGBM Normal glomerulus

demonstrate GBM
1
Jones methenamine silver stain
Stephen M. Bonsib. Atlas of Medical Renal Pathology. 2013th Edition. Springer Science & Business Media.
 (demonstrated by HAE)
Amyloidosis also havespike
I found systemic lupus)
in

spike (not immune deposit)

/
↓ podocyte in response to
immune deposit

V
 Immunohistochemistry

• FFPE tissue
• specific antibodies against amyloid subunits
amyloidosis ATTR

(AA or AL amyloid, transthyretin, etc.)

↓ amyloid depositioner
carrier that
carry thyroid
hormone ->
or

• antibodies against viruses (cytomegalovirus,

polyomavirus and adenovirus)
 Immunohistochemistry
- graft biopsies
• immunostaining for the C4d fragment of the
complement pathway
➢helpful in the diagnosis of acute humoral
rejection
• BK polyoma virus (SV40)
& infectin childhood but remains latent a deposit in kidney

➢screening and early treatment is beneficial for

long-term transplant survival
➢reducing the amount of immunusuppressive
(anti-rejection) medication can help to decrease
the virus
 BK polyomavirus

(detect by Abagainst
inclusions BK vies)
/
L
+

large nucleus

Stephen M. Bonsib. Atlas of Medical Renal Pathology. 2013th Edition. Springer Science & Business Media.
Immunofluorescence (IF)
 Frozen sectioning
• Cut one section for rapid HE to confirm the
presence of glomerulus
• If no glomerulus (trim the block gradually ->DE*5 trima]
EBEADIJAT] gomenchus

➢cut deeper if the tissue is cortex

➢take another frozen block from if the tissue is
medulla take
frozen
a new
block
I
➢Still no cortex identified, all the renal tissue
should be fixed and paraffin processed
• Report any difficulty
 Frozen sectioning
• If the glomeruli are identified, a set of 20
10: (I frozen HE 9IF)
+

consecutive sections, each 6 µm thick is cut

for direct IF, -ve control, H&E, and spares
• Frozen sections are kept at -20OC
• Remaining block is stored at -70OC
 Result interpretation
• Not only report whether the reaction is
positive
• Compartment
➢Glomerulus, tubular BM, peritubular capillaries
• Relative intensity
• Pattern of staining
➢mesangial vs capillary
➢linear (or pseudolinear) vs granular
Two patterns of deposition of immune complexes as seen by immunofluorescence microscopy.
A, Granular, characteristic of circulating and in situ immune complex deposition. B, Linear, characteristic of
classic anti-glomerular basement membrane (anti-GBM) antibody glomerulonephritis.

Aster. Robbins and Cotran Pathologic Basis of Disease. Ninth edition. Philadelphia, PA: Elsevier/Saunders, 2015.
Tubulointerstitial positivity
• Tubulointerstitial positivity for
Igs or complement can be see in
some autoimmune disease,
mainly lupus, and exceptionally
in other diseases.

(Immunofluorescence for IgG, anti-human-IgG antibodies marked

with fluorescein, fluorescence microscopy, X400).

http://www.kidneypathology.com/English_version/Histologic_patterns.html
Electron microscopy
Transmission Electron Microscopy (TEM)
• Ultrastructure helps to determine important
features in differential diagnosis
• Minimal change disease is the glomerulopathy
that more requires EM, since it is, by definition,
an ultrastructural diagnosis
Transmission Electron Microscopy (TEM)
Tolaidine blue
stainby metachromasiaby

• Fixation
➢1 mm3 cortical tissue are fixed in 3% glutaraldehyde in
0.1 M sodium cacodylate-HCl buffer pH 7.4 for overnight
at 4°C
• Tissue can be reprocessed from paraffin or
frozen blocks to EM but artefacts may result
• TB stained 1um thick section to identify
appropriate structures for thin sectioning
• 1-2 glomeruli are examined ultrastructurally
• Low medium & high magnification photographs
are taken
Transplant Biopsy
 Renal allograft biopsy

• provides much more information than blood

tests at the microscopic level
• identify early scarring that can happen with
chronic rejection, injury to the kidney from
medications, or silent rejection that can occur
without causing the creatinine to go up
Dragtoxicity
or

• help to make the best decisions for treatment

➢For example, silent rejection can be treated with a
short course of extra anti-rejection drugs
 Renal allograft biopsy
• For acute management of rapid deteriorating
renal function
➢Rejection vs anti-rejection drug toxicity
➢Cellular vs humoral rejection
➢Rejection vs infection
Stransplant biopsy

• Urgent biopsy
 Renal allograft biopsy
• biopsy reporting uses the Banff classification
• provides information regarding
➢type of rejection
➢intensity of rejection
• The specific therapeutic strategy is directly
linked to these information
• Immunohistochemistry - graft biopsies
 HdE
/NRBCS
Hyperacute rejection (should be vein normal cases #
NWBCs
IgG/m+reCtubules glomerulus)
+

extensive necrosis + V
X
hemorrhage

Stephen M. Bonsib. Atlas of Medical Renal Pathology. 2013th Edition. Springer Science & Business Media.
& Are in tabular Ba
not GBM
END