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^Kidney biopsy –
technique, interpretation, evaluationEberhard Ritz
Heidelberg (Germany)
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UroscopyDavid Teniers (1610-1690)
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History :
Brun C. et alKidney biopsy in acute glomerulonephritis
Acta Med. Scand.(1958) 166: 155
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percutaneous renal biopsy
BioptyR gun (Radioplast AB)
adaptor (UAGV 009A, Toshiba Co.)
- in the past primary biopsies overnight in hospital
- transplant protocol biopsy 12h observation
and then dismissal
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Complications- 1/1090 cases requiring interventional radiology (coil)
- 3/1090 cases blood transfusion
- no persisting hemodynamically relevant av fistules
- small hematomas (> 2x2 cm without decrease of Hb)
in 2,2%
Hergesell, Nephrol.Dial.Transplant. (1998) 13: 975
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Renal biopsy only when :
- strict normotension (< 140/90 mmHg)
- normal coagulation parameters(PT, PTT, f VIII, thrombocyte counts, bleeding time)
- no Aspirin or other non-steroidal antiinflammatory
agents for at least 5 days
- no (active) urinary tract infection
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Main indictions for renal biopsy
abnormal proteinuria andpathological urinary sediment (phase contrast)
main purpose of biopsy diagnostic : is there a renal problem(e.g. vs orthostatic proteinuria)renal vs postrenal problem(biopsy vs urological investigation)
additional reason prognostic : activity of the process
(e.g. rebiopsy vs watchful waiting)
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Akanthocytes
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Erythrocyte casts
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Cellular casts
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Investigations prior to renal biopsy
- kidney ultrasonographysingle kidney?orthotopic?normal width of parenchyma?aberrant vessels (Duplex-sonography)
- blood pressure < 140/90 mmHg- normal PT, PTT, f VIII, thrombocytes, bleeding time- sterile urine culture
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Yield of kidney biopsy
-sufficient tissue for histopathology1077/1090 = 98,8%
- Glomeruli per cylinder n=9 (1-37)
Hergesell, Nephrol.Dial.Transplant. (1998) 13: 975
Dream of pathologists : entire kidney(diagnostic autopsy)Consensus conference (Wien, 2001) :8 glomeruli, optimal 10-15
http://www.kidney-euract.org/Rbpathology/ consensus.htm
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“If the percentage of glomerular involvement in a biopsyis used to determine the severity of a focal lesion, asmall biopsy sample size will lead to considerablemisclassification of disease severity and will makeexclusion of focal disease difficult“
Corwin, Am.J.Nephrol.(1988) 8:85
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• 2 biopsy cylinders• minimal length 1 cm• diameter 1.2 mm
# isotonic saline – fast local transport• cryopreservation of one piece for immunefluorescence• fixation with paraformaldehyde or buffered (4%)
formaldehyde for paraffin embedding• fixation with 3% glutaraldehyde for electron microscopy
or
# direct fixation with paraformaldehyde or formaldehyde and shipping (indirect immunehistology by APAAP (alkaline phosphatase) or others
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Routine stainsinformation complementary
HE-stain(hematoxylin-eosin)
PAS-stain(Periodic acid-Schiff’s base)
composition of tissue:cortex vs medulla,number of glomerulicellular infiltrates ..
analysis of glomerulus and vessels:glomerular cells,mesangial matrixglomerular basement membranefibrinoid necrosis ..
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Routine stainsprotein stain
(SFOG; acid fuchsin-Orange G)silver stain
immune depositsin this section: subendothelial and intramembranous
changes of basement membranee.g. thickening, reduplication, spikes
for specific indications Congo red or Kossa stain
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Routine stainsImmunefluorescence Immunehistochemistry
(antiperoxydase method)
immune deposits:here IgG ab, IgG deposits
immune deposits:antiperoxydase method
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Electron microscopy :glutaraldehyde fixation or initially formaldehyde
• Alport’s disease• thin basement membrane disease• immunotactoid disease• minimal change nephropathy (foot process fusion)• (amyloidosis, L-chain deposit disease...)• (lupus: fingerprints; tubuloreticular structures..)
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Why renal biopsy ?What are the goals ?
1. diagnosis (specific therapy?)
2. prognosis
3. acute (reversible) vs chronic (irreversible) changes (e.g.aggressive immune suppression yes/no)
4. diagnosis of superimposed second kidney disease, e.g.
IgA-GN after : Wegener’s granulomatosis,Wegener’s granulomatosis + Goodpasture etc.
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For which nephrologic syndromes shouldrenal biopsy be considered :
- asymptomatic hematuria(dysmorphic erythrocytes,erythrocyte casts) + proteinuria
- nephrotic syndrome
- acute nephritic syndrome- rapidly progressive glomerulonephritis !!! (nephrological emergency)
- (chronic renal failure; CKD)- (acute renal failure; AKI)- renal transplantation
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Differential diagnosis ofasymptomatic hematuria ± proteinuria
• IgA glomerulonephritis
• Alport’s disease
• (thin basement membrane disease)
• lupus erythematosus
• (initially) isolated renal manifestation of vasculitis
• membranoproliferative glomerulonephritis
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diagnosis ?
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IgA glomerulonephritis
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IgA-GN (Schönlein-Henoch purpura)
IgA1 IgG1 complexes (circulating? planted?)-reduced galactosylationof O-linked serin residuesat hinge region (hominoid)
IgG1 autoantibodieswith mutation IgG VHepitope : galactose-deficient IgA1
+C3 no C1q →
alternate pathway ormannose binding lectin
pathway
Caveat: 4% normals have IgA depositsno (less?) codeposition IgG1 and C3
Suzuki, J.Clin.Invest.(2009) 119:1668
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Hudson (2003) New Engl.J.Med. 348: 2543
6 chains of collagen IV: α1-α63 noncollagenous NC domains associate as a trimeric cap
to form protomers interacting with adjoining protomerin adult glomerular basement membrane α3,α4,α5 (IV)
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Hudson, New Engl.J.Med.(2003) 348: 2543
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• 85% of X-linked Alport mutation : COL5A5 gene(hematuria, proteinuria, renal failuresensorineural hearing loss, lenticonus, oil droplet sign)alternative to renal biopsy : skin biopsy ( absent COLI4α5 epitope)
• autosomal recessive Alport :compound heterozygotes or homozygous for mutations in COL4A3 or COL4A4 genes
• concomitant mutations in COL4A6 :additional leiomyomatosis
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Benign hematuria~ thin basement disease
• 1-14% of general population
• genetically heterogeneous (in 40% mutations in genes COL4A3/COL4A4), 2/3 have autosomal dominant form
• GBM attenuated diffusely as in early Alport or carriers of autosomal recessive Alport
• some cases develop proteinuria, hypertension and impairedrenal function
• benign familial hematuria =may be carrier state for autosomal recessive Alportsyndrome
Tazón,Am.J.Kidn.Dis.(2003) 42:952
Savige, Brit.Med.J. (2001) 322: 942
Nieuwhof, Kidn.Intern.(1997) 51:1596
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Diagnostic yield of kidney biopsy –isolated microhematuria vs.
microhematuria plus moderate proteinuria
89 pat. isolated microhematuria, 46 pat. microhematuria and moderate proteinuria (<2,5g/Tag)hypertension in 36% and 56% respectively
isolated microhematuriathin basement nephropathy 43 %IgA-glomerulonephritis 20 %nonspecific abnomalities 19 %normal 18 %
microhematuria plus proteinuriaIgA-glomerulonephritis 46 %other forms of GN 26 %nonspecific abnormalities 17 %normal 4 %
Hall, Clinical Nephrol. (2004) 62:267
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For which nephrologic syndromes shouldrenal biopsy be considered :
- asymptomatic hematuria(dysmorphic erythrocytes,erythrocyte casts) + proteinuria
- nephrotic syndrome
- acute nephritic syndrome- rapidly progressive glomerulonephritis !!! (nephrological emergency)
- (chronic renal failure CKD)- (acute renal failure AKI)- renal transplantation
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Differential diagnosis of the nephrotic syndrome
• minimal change nephropathy/focal segmental glomerulosclerosis (FSGS)
• primary glomerulonephritis membranous GNmembranoproliferative GN
• systemic diseases diabetes (type 1 and 2)
• heredofamilial renal disease Alport‘s syndromenail patella syndrome
• protein deposit diseases amyloidosis (AL, AA, transthyretin, fibrinogen.....)light chain deposit disease(heavy chain deposit disease)
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normal
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foot process fusion
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focal segmental glomerulosclerosis(adhesions, mesangial scars)
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focal-segmental glomerulosclerosis (FSGS) –potential causes
- primary (idiopathic) FSGS
- HIV- or Heroin-associated FSGS(collapsing nephropathy)
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Collapsing glomerulonephritis
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Secondary focal-segmental glomerulosclerosispotential causes
# reduced renal massoligomeganephroniaunilateral renal agenesisrenal dysplasiareflux nephropathymassive surgical loss of renal masschronic renal graft failure
# normal renal mass diabetesobesitycyanotic cardiac disease
HNF1, OFD,Wt1,ROBO2
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diabetic glomerulosclerosis(Kimmelstiel Wilson)
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Differential diagnosis of the nephrotic syndrome
• minimal change nephropathy/focal segmental glomerulosclerosis (FSGS)
• primary glomerulonephritis membranous GNmembranoproliferative GN
• systemic diseases diabetes (type 1 and 2)
• heredofamilial renal disease Alport‘s syndromenail patella syndrome
• protein deposit diseases amyloidosis (AL, AA, transthyretin, fibrinogen.....)light chain deposit disease(heavy chain deposit disease)
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membranous glomerulonephritis
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spikes
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Membranous glomerulonephritis
• poor prognosis –only nephrotic proteinuria
• predictors of progression- male gender- age- nephrotic range proteinuria- IgG/α1 microglobulin ratio in urine- focal segmental lesions
• etiology : phospholipase-receptor 2 antibodies
deBuf-Vereijken, Am.J.Kidn.Dis.(2005) 46:1012
Lai,Kidn.Internat.(2007) 71:841
Beck, New Engl.J.Med.(2009) 36:11
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Differential diagnosis of the nephrotic syndrome
• minimal change nphropathy/focal segmental glomerulosclerosis (FSGS)
• primary glomerulonephritis membranous GNmembranoproliferative GN
• systemic diseases diabetes (type 1 and 2)
• heredofamilial renal disease Alport‘s syndromenail patella syndrome
• protein deposit diseases amyloidosis (AL, AA, transthyretin, fibrinogen.....)light chain deposit disease(heavy chain deposit disease)
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glomerular amyloidosis
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Congored stainunder polarized light
(“applegreen”)
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congored stain and polarized light –tubular amyloidosis
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mesangial amyloid depositselectron microscopy
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Causes of (secondary) AA amyloidosis
• rheumatoid arthritis or juvenile RA 56 %• chronic infection 14 %• ankylosing spondylitis 8 %• psoriatic arthritis 5 %• familial mediterranian fever 3 %• Crohn‘s disease 3 %• others 11 %
Gorevic, update patient information
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• acquired forms :
# AA amyloidosis – chronic infection or inflammation
# AL amyloidosis – plasma cell dyscrasia(κ/λ 1:3 vs 3:2 in controls; usually the rare λVI and κI subgroups)
• hereditary forms (with renal involvement) :
transthyretin (binding thyroxin and retinol binding protein),apo-Lipoprotein A I,II , lysozym, fibrinogen A α
Lachmann, New Engl.J.Med.(2002) 346:1786
Amyloidoses
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alternative possibilities biopsy(less invasive?)
• abdominal fat• rectal mucosa• bone marrow
• renal biopsy :vascular amyloidosis →vessel contraction↓ → bleeding risk↑
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For which nephrologic syndromes shouldrenal biopsy be considered :
- asymptomatic hematuria(dysmorphic erythrocytes,erythrocyte casts) + proteinuria
- nephrotic syndrome
- acute nephritic syndrome- rapidly progressive glomerulonephritis !!!( nephrological emergency ! )
- (chronic renal failure CKD)- (acute renal failure AKI)- renal transplantation
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crescent
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Differential diagnosis of rapidly progressive glomerulonephritis (RPGN)
immunecomplex-GN postinfectiousSchönlein Henoch purpuraSLE (lupus)
antibasalmembrane Ab GN isolated GNGoodpasture syndrome(with hemoptyses)combination with pauciimmune GN
pauciimmune RPGN Wegener’s granulomatosismicroscopic polyangiitis
differential diagnosis: HUS (EHEC, idiopathic), malignant hypertension, scleroderma-crisisCave: combination HUS plus glomerulonephritis
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Renal biopsy in diabetes
# no biopsy if :- typical evolution of renal disease - accompanied by retinopathy
# consider biopsy if :- atypically early onset of renal abnormalities
(< 10 years in type 1 diabetes)- dysmorphic erythrocytes + erythrocyte casts - rapid deterioration of renal function- increased S-creatinine without urinary abnormalities- extremely high proteinuria (~7g/day)
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Histologic findings in patientswith type 2 diabetes and abnormal renal findings
303 biopsies
- diabetic glomerulosclerosis 51%
- atherosclerotic/ischemic lesions 16%
- primary nephropathy ( isolated or superimposed) 33%
Mazzuccho, Am.J.Kidn.Dis. (2002) 38: 713
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For which nephrologic syndromes shouldrenal biopsy be considered :
- asymptomatic hematuria(dysmorphic erythrocytes,erythrocyte casts) + proteinuria
- nephrotic syndrome
- acute nephritic syndrome- rapidly progressive glomerulonephritis !!! (nephrological emergency)
- (chronic renal failure CKD) exceptions: Fabry, Balkan nephritis…
- (acute renal failure AKI)- renal transplantation
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For which nephrologic syndromes shouldrenal biopsy be considered :
- asymptomatic hematuria(dysmorphic erythrocytes,erythrocyte casts) + proteinuria
- nephrotic syndrome
- acute nephritic syndrome- rapidly progressive glomerulonephritis !!! (nephrological emergency)
- (chronic renal failure CKD)- (acute renal failure AKI)- renal transplantation
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Reasons to consider renal biopsy inpatients with acute renal failure (AKI)
- progressive loss of renal function- persisting oliguria- (absence of obvious causes of ARF)- pronounced proteinuria/hematuria(consider Hanta and exclude vasculitis !!!)
- pronounced hypertension (exclude HUS, malignant hypertension, scleroderma crisis)
- history of glomerulonephritis- suspicion of drug allergy or tubular obstruction by drug crystalluria
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Thank you for yourattention
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Nephrologische Syndromebei denen Nierenbiopsie zu erwägen ist- asymptomatische Hämaturie(dysmorphe Erythrozyten,Erythrozytenzylinder) + Proteinurie
- akutes nephritisches Syndrom- rasch progrediente Glomerulonephritis !!!- nephrotisches Syndrom- (chronische Niereninsuffizienz)- (akutes Nierenversagen)- Nierentransplantat
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Akute Oligoanurie nach Nierentransplantation- prärenale Ursache (Salz/Volumen-Depletion)- perakute Abstoßung*- akutes Nierenversagen*- Calcineurin-Inhibitor-Toxizität*(Cyclosporin A, Tacrolimus)
- arterielle oder venöse Thrombose (+ Transplantatnekrose)- HAES-Schäden (Hydroxyäthylstärke) nach Vorbehandlungdes Spenders*
- Virusinfektionen- nephrotoxische Antibiotika- Lymphocele/Obstruktion- rekurrierende Grunderkrankung (FSGS, Oxalose)*
* Diagnose durch Biopsie zu stellen
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Chronisches Transplantatversagen- chronische Allograft-Nephropathie*- Calcineurin-Inhibitor-Toxizität*- rekurrierende Grundkrankheit*- de novo Glomerulonephritis*- diabetische Nephropathie (Diabetes vorbestehend oder de n- HUS (rekurrierend oder Folge der Calcineurin-Hemmer)*- Viruserkrankung (CMV, Polyoma .....)*- Stenose der Transplantat-Arterie oder der Iliaca- Cholesterin-Embolie*- Hypercalcämie, Oxalose, Oxypurinol-Nephropathie*- Harnwegsobstruktion- Harnwegsinfekt
* Diagnose durch Nierenbiopsie zu stellen
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Nephrologische Syndromebei denen Nierenbiopsie zu erwägen ist- asymptomatische Hämaturie(dysmorphe Erythrozyten,Erythrozytenzylinder) + Proteinurie
- akutes nephritisches Syndrom- rasch progrediente Glomerulonephritis !!!- nephrotisches Syndrom- (chronische Niereninsuffizienz)- (akutes Nierenversagen)- Nierentransplantat
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TTöörnrothrnroth (2003) (2003) AJKDAJKD 4242: 960: 960
Interstitial lymphoma
May-Grünwald-Giemsa, 170x
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TTöörnrothrnroth (2003) (2003) AJKDAJKD 4242: 960: 960
Intraglomerular lymphoma
May-Grünwald-Giemsa, 100x
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TTöörnrothrnroth (2003) (2003) AJKDAJKD 4242: 960: 960
Intraglomerular lymphoma
anti-CD20, 40x
arrows: uninvolvedglomeruli
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TTöörnrothrnroth (2003) (2003) AJKDAJKD 4242: 960: 960
Intracapillary localization of lymphoma cells
anti-CD20, 270x
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TTöörnrothrnroth (2003) (2003) AJKDAJKD 4242: 960: 960
Nuclear atypia and nucleosis of lymphoma cells
May-Grünwald-Giemsa, 420x
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before after
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c-ANCA p-ANCA
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nail-patella syndrome:mutation of transcription factor LMX1Bcontrolling expression of COL4A3,COL4A4,nephrin,podocin …
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• characteristic lesions of glomerular basement membrane– rarefications, lucent areas (“moth eaten”)– with cross-striated collagen fbrils (type III)
• disease does not recur in transplant• kidney of donors with nail patella syndrome suitable for
transplantation
Del Poso (1970) Am J Pathol 54: 845
Vega (1997) Nephrol.Dial.Transplant. 12: 1742
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Tazón, Am.J.Kidn.Dis.(2003) 42: 952
Problems of “benign hematuria“two heterozygotes may produce offspring with Alport syndrome
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misclassification of hereditary amyloidoses
• 350 patients with systemic amyloidosis diagnosed as AL type and had no known family history(only 85% of AL amyloidoses have monoclonal proteins in serum or urin, therefore confirmation by biopsy indispensable)
• amyloidogenic mutations in 34/350 patients (9,7% !!)mostly fibrinogen A α or transthyretin
• failure to make the diagnosis of hereditary amyloidosisexplained by fortuitous combination of low grademonoclonal gammopathy in 8/34 patients (24%!!)► erroneous therapy : cytotoxic treatment instead of liver
transplantation
Lachmann, New Engl.J.Med.(2002) 346:1786
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