RENAL BIOPSY presentation and lecture on
- 1. RENAL BIOPSY Dr. Karishma Makwane Moderator- Dr. Rajni Chaudhary
- 2. INTRODUCTION: – The renal or kidney biopsy is a valuable tool that has became the gold standard for the diagnosis of pathologic kidney diseases since early 1950s. – With the advent of newer diagnostic stains and microscopic techniques, including immunofluorescence and electron microscopy, the field of renal pathology began to flourish as subspecialty of surgical pathology. – Renal biopsy has became a preferred method to obtain critical information that can be used in conjunction with serology, urinary and genetic testing to diagnose a variety of kidney diseases, Acute or Chronic.
- 3. HISTORY • The first surgical biopsy of the kidney was performed by Dr. George Edelbohls in patient of Bright disease. • 1951 : Percutaneous renal biopsy, based on the use of an aspiration needle and the patient in the sitting position was first described by Iversen and Brun • 1954 : Kark and Muehrcke described the use of the cutting Franklin- modified Vim-Silverman needle on patients in the prone position, with a substantial improvement in the rate of success • Recent widespread availability of real time imaging using ultrasound and Computerised Tomography (CT) scanning have improved the safety of the procedure and also aid in the use of biopsy guns.
- 4. • The kidneys are a pair of excretory organs situated retroperitoneally • Within the perirenal space, which contains abundant fat & is enclosed by the anterior and posterior layers of renal fascia, known as Gerota’s fascia. • Poles : Upper & Lower • Borders : Medial & Lateral • Surfaces : Anterior & Posterior Location : T12 to L3 ANATOMY
- 5. Kidney biopsy is currently done for three major reasons : • To establish the pathologic diagnosis • To provide insight into the treatment options • To provide prognostic information or gauge response to therapy
- 6. Additive role of various sources of information used to generate a diagnosis in renal biopsies.
- 7. Indications for Renal Biopsy: diagnose d n resolving clinical ATN >3- eeks emic diseases with renal unction nephrotic proteinuria /d in DM, early MGN, GS, IgAN Nephrotic syndrome: o Adult NS o Children with atypical features Acut o Un o No 4 w Syst dysf Sub- o >2 F S o <2g/d needs clinicians discretion o Hematuria CKD- e renal failure: o generally contraindicat o In moderate dysfunctio Post transplant ed n- b a s i c potential reversibility a disease Diabetes Mellitus o Microscopic hematuria o Absence of retinopathy neuropathy o Onset of proteinuria <5 and ar s from diagnosis o Acute worsening of renal function o Systemic features
- 8. TYPES: – The great majority of renal biopsies performed are Needle biopsies. – Percutaneous renal biopsies are associated with low morbidity and mortality and usually provide enough material for adequate diagnosis. – 14 or 19-gauge needles are generally used to perform the biopsies. – Only in rare cases an open renal biopsy is the specimen obtained for examination. – Either a wedge shaped renal sample or needle biopsy or both represent the most common specimens obtained when open renal biopsy is performed. – Fine needle aspiration has been used to evaluate for rejection in transplanted kidneys with variable success. –Other techniques: 1.Transjugular 2. Laparoscopic 3. Open surgical approach
- 9. PROCEDURE Most percutaneous biopsies are performed under ultrasound or CT guidance Pre-requisites : • Informed written consent • Blood coagulation tests • Blood grouping & typing • Cross matching • Recording patient’s vital signs • Placing intravenous line • Employing appropriate imaging method to visualise the kidneys
- 10. Biopsy needle Recommendation: Upto age 7 - 18 gauge Age 8 and older -16 gauge Imaging : • Real-time imaging of the kidney during insertion of the biopsy needle is the preferred method for performing a percutaneous biopsy • Several imaging tools can be used including renal ultrasound with colour Doppler, CT & Magnetic Resonance Imaging (MRI) • Advantage : Visualisation of the biopsy needle as it passes through the skin into the kidney
- 11. PROCEDURE – NATIVE KIDNEY • Patient is placed in prone position • Skin is marked after imaging the kidney and identifying the lower pole, where the biopsy needle will be inserted • Aseptic precaution of the skin is employed • The skin & subcutaneous tissues are anaesthetized and a small incision is made in the skin • The patient takes a breath and holds and the needle is positioned in the kidney
- 12. COMPLICATIONS: *Bleedding events( Reteroperitoneal Haematoma ) is most common complication which is likely explained by the great vascularity of the kidneys ( 25% of the cardiac output ). *Gross haematuria which rarely lead to clot formation and urinary outlet obstruction. *Arteriovenous fistula. *Death(0.5-1%) #Optimization of blood pressure and attention to risks may help reduce the risks.
- 13. Post biopsy : 1. Observe the patient for complications 2. Especially bleeding – minimum 4 hours 3. Monitor vital signs 4. Monitor for severe back, flank or abdominal pain and gross hematuria 5. Serial haemoglobin and haematocrit should be monitored.
- 14. RELATIVE CONTRA-INDICATIONS: Kidney status Patient status • Polycystic diseases of kidney • Uncontrolled bleeding diathesis • Solitary kidney • Uncontrolled hypertension • Pyelonephritis/ Perirenal abscess • Hypotension • Hydronephrosis • Morbid obesity • Atrophic/ small kidneys(<8cm) • Vascular AV fistula • Renal neoplasms • Severe anemia • Uremia • Un co-operative patient
- 15. PROCEDURE – TRANSPLANT KIDNEY • Nephrologists are confronted with an increasing number of renal transplant biopsies. • Indications are: 1. To determine degree of rejection 2. Evaluate complications affecting the transplanted kidney 3. Analyze toxicity by the immunosuppressive drugs 4. To evaluate for the presence of recurrent or de novo glomerulonephritis or transplant glomerulopathy 5. To decide the need to increase, alter or stop immunosupression, and 6. To judge the prognosis of renal allograft. *More recently, C4d staining has been proposed to be very useful in depicting a subset of rejection patients that would not be detectable by light microscopy.
- 16. • Indication : Impaired excretory function Graft dysfunction • Two common problems: • Active, acute rejection that may respond to treatment OR • Chronic damage that will not respond to treatment • The diagnoses related to acute rejection : • Antibody-mediated rejection • Acute cellular rejection • Acute vascular rejection • Severe acute vascular rejection *The Banff group suggested in 1997 for transplant biopsies.
- 17. SAMPLE ADEQUACY: Whenever possible, demonstration of sufficient tissue including at least seven glomeruli should be ascertained at the bedside using low-power dissecting microscope. Hand held lens/dissecting microscope can be used to check for the presence of cortical tissue.
- 18. Two biopsy cylinders with a minimal length of 1 cm and a diameter of at least 1.2 mm. 10–15 glomeruli are optimal; very often 6–10 glomeruli are sufficient Some cases even one glomerulus is enough Nephrol Dial Transplant (2006) 21: 1157–1161 Adequacy depends on the pathology - Focal lesions may be missed out 1-2 glomeruli 3-5 glomeruli 5-10 glomeruli Electron Microscopy Immunofluoresence light Microscopy
- 19. PROCESSING: 2 cores of tissue are obtained whenever possible, to provide an adequate sample for light, immunofluorescence and electron microscopy • Immunofluorescence • Light microscopy First core Electron microscopy • There is a need to divide the second core, submitted in formalin. The two tips of the second core are then submitted for electron microscopy and remaining of the second core for light microscopy. Second core
- 20. 10 % NB Formalin No fixation (Frozen) 4% Gluteraldehyde 10% NB Formalin Light Microscopy Immunofluorescence (Michelle’s Transport medium) Electron microscopy Techniques & Preservatives:
- 21. Electron microscopy : Fixatives : 1. 3% phosphate-buffered glutaraldehyde 2. 2.5% glutaraldehyde in a cacodylate buffer Postfixation in 1% osmium tetroxide is recommended Tissue should be cut into fragments no larger than 1x1x1 mm If no glomeruli present Tissue can be reprocessed from the paraffin block
- 22. INTERPRETATION OF RENAL BIOPSY The best approach to achieve an accurate pathologic diagnosis is to recognize the patterns of injury found in each of the four compartments of the kidney : • Glomeruli • Tubules • Interstitium • Vessels
- 24. Structure of the Glomerulus
- 26. Glossary of descriptive terms • Focal Involving some glomeruli • Diffuse Involving all glomeruli • Segmental Involving part of glomerular tuft • Global Involving total glomerular tuft • Lobular Hypersegmentation of normal lobular appearance of capillary loop architecture due to endocapillary proliferation • Nodular Relatively acellular areas of mesangial matrix
- 27. • Glomerulosclerosis Increased collagenous ECM expanding mesangium, occluding the capillary lumen or forming adhesions to Bowman`s capsule • Crescent Proliferation of parietal epithelial cells, podocytes, infiltrating inflammatory cells. >2 cell layer in Bowman`s space • Spikes Projections of glomerular BM intervening between subepithelial immune deposits • Hyalinosis Descriptive of glassy smooth appearing acellular material
- 28. • Mesangial area Stalk region of capillary loop with mesangial cells surrounded by matrix • Mesangial hypercellularity 4 or more nuclei in a peripheral mesangial segment • Subepithelial • Subendothelial Between visceral epithelial cells and GBM Between endothelial cells and GBM • Tram- track Double contour of GBM due to deposits
- 29. Glomerular changes • Focal/diffuse • Segmental/global • % of glomeruli involved • Glomerular size • Glomerular cellularity • Glomerular capillary potency • GBM changes • Mesangial widening • Mesangial cellularity Tubules, interstitium ,vessels • Focal/diffuse • Estimate of severity Negative findings • Absence of necrosis • Absence of amyloid
- 30. Stains Hematoxylin & Eosin : (H&E) • Glomerular : Exudative lesions • Tubular : Epithelial damage • Interstitial : Edema, Inflammation • Vascular : Inflammation
- 31. Periodic Acid Schiff reaction : • Glomerular : GBM, capillary wall collapse • Hyalinosis • Sclerosis • Mesangial cellularity , matrix increase • Tubules : Protein droplets, tubular basement membrane • Vascular :Hyaline arteriosclerosis
- 32. Methenamine-silver (Jones stain) : • Glomerular : GBM spikes, double contour • Breaks in GBM • Tubular :Tubulitis • Interstitial : Fibrosis
- 33. Masson Trichrome : • Glomerular : Immune deposits • Thrombi • Fibrin • Platelets • Tubular :Tubular atrophy • Interstitial : Fibrosis
- 34. IMMUNOFLUROSCENECE Reach an unstable excited state as its electrons gain energy. Fluorochrome conjugated to the antibody absorbs ultraviolet or visible light of a particular wavelength PRINCIPLE :
- 35. Fluorochrome subsequently emits light of a different, usually longer, wavelength to that of the excitation light ,as the electrons return to their ground state.
- 36. Based on principle that exciting radiation from UV light of shorter wavelength causes flourescence of certain substances and thereafter reemits of longer wavelength. Fluorescence microscope Leica LED 2000
- 37. TYPES Immunofluorescence (IF): • Tissues can be transported to the laboratory either : 1. Fresh ( saline-soaked gauze) or 2. Zeus or Michael medium Immunoperoxidase (IP): Done when : • Frozen tissue is not available • Glomeruli are not present on frozen sections
- 38. Patterns of IF in Renal Biopsies *Specific or non specific. *Linear or Granular *Location *Semiquantification of intensity (0 to 3+)
- 39. A routine antibody panel for IF on native kidney biopsy: • IgA/M/G • C3 • C1q • Fibrinogen • /κ light chains ʎ • Collagen IV alpha chains • Allograft renal biopsies: C4d
- 40. BIOPSY INTERPRETATION POSITIVE RESULTS • DISTRIBUTION (E.G. GLOMERULUS, TUBULOINTERSTIT IAL, AND/OR BLOOD VESSELS) • GLOMERULAR LOCALIZATION (CAPILLARY ,MES ANGIAL, PODOCYTE) • PATTERN (LINEAR, GRANULAR) • INTENSITY (1-4+) INTENSITY ON SLIDES ARE EVALUATED ON A 0 – 4 +SCALE • NONE (0) • TRACE (0.5+) • MILD (1+) • MODERATE (2+) • MODERATELY SEVERE (3+) • SEVERE (4+) • WHICH ANTISERA POSITIVE ( IgG, IgA….) NEGATIVE RESULT
- 41. Glomerular diseases: Causing Nephrotic Syndrome : Non- Immune Complex Causing Nephrotic Syndrome : Immune Complex Causing Nephritic Syndrome : Immune Complex Causing Nephrotic- Nephritic Syndrome : complement related •Acute Post- Infectious GN •IgA Nephropathy •MCD •FSGS •Diffuse Mesangial Sclerosis •Congen Nephrotic Syndrome of Finnish Type •Membranous Nephropathy •Membranoproliferative GN •Fibrillary GN •Immunotactoid Glomerulopathy •C1q Nephropathies •C3 Glomerulopathies
- 42. – Coarse, granular staining of glomerular capillary loops with IgG and C3. – Less frequently IgM, IgA and early complement components (C1q, C4). – Electron dense sub-epithelial “hump” 1.Post-infectious glomerulonephritis:
- 43. 2.MEMBRANOPROLIFERATIVE GN TYPE 1: (Immune complex) Fine to coarse granular pattern along the glomerular capillaries & mesengium. strongly positive for IgG, C3 C1q/C4 ++ TYPE 2: (Dense deposit) Granular or linear intense staining for C3, glomerular capillary walls and mesangial regions (mesangial rings) C1q/C4 -- TYPE 1 TYPE 2
- 44. Light microscopy : • Glomeru • GBM – li – Large, Hypercellular “Double-contour” or “tram-track appearance” Due to duplication of basement membrane (splitting) : New basement membrane synthesis in response to subendothelial deposits of immune complexes
- 45. Generalized peripheral granular staining for IgG & C3,K, Lambda along GBM(diffuse). **The presence of IgA & C1q/C4 :marker for SLE Membranous Nepthropathy. Electron microscopy: Subepithelial electron dense deposits. Membranous nephropathy
- 46. CRESCENTIC GLOMERULONEPHRITIS (RAPIDLY PROGRESSIVE)-RPGN .TYPE I (ANTI- GBM ANTIBODY- MEDIATED DISEASE) : continuous linear lace like IgG and C3 staining along capillary walls. TYPE II(IMMUNE COMPLEX DEPOSITION) coarse granular deposits of IgG in mesengium & along capillary wall. . TYPE III (PAUCI- IMMUNE) : negative/very weak staining, TYPE 1 TYPE 2
- 47. Type I • Disruption of GBM • No immune-type electron dense deposits Type II Numerous subendothelial, subepithelial, mesangial electron-dense deposits
- 48. IgA Nephropathy (Berger’s disease) Light microscopy : Glomeruli may be : • Normal • Mesangioproliferative Glomerulonephritis • Focal proliferative Glomerulonephritis • Crescentic Glomerulonephritis Mesangial proliferation and matrix increase
- 49. Deposition of IgA in mesangial regions Granular immune-type dense deposits in the mesangium
- 50. Focal Segmental Glomerulosclerosis (FSGN): Characterised by : Focal • Sclerosis of some, but not all glomeruli • In the affected glomeruli, only a portion of the capillary tuft is involved Segmental By light microscopy, the lesions may involve only a minority of the glomeruli and may be missed if the biopsy specimen contains an insufficient number of glomeruli
- 51. • IgM and C3 may be present in the sclerotic areas and mesangium IgM C3
- 52. Lupus nephritis • Class I:delicate mesangial positivity for IgG • Class II : granular mesangial positivity of all three Ig and both complements (C1q and C3) (“full house” pattern)
- 53. Lupus nephritis • Class III : full house pattern as in class II, also in tubular basement membranes, interstitial capillary walls, interstitial collagen, arterial intima/media. • Class IV : same as class III but affecting > 50% glomeruli
- 54. Lupus nephritis • Class V : There are delicate IgG with or without mesangial deposits
- 55. Class VI : Sclerosis of more than 90 % glomeruli without residual activity. Small granular immune deposits in the thickened and sclerotic GBMs, in the fibrotic tubulointerstitial compartment, or in vessel walls Lupus nephritis
- 56. SUMMARY Disease IF E/M PSGS Granular;IgG & C3 Subepithelial humps Subendothelial deposits MPGN TYPE I Granular;IgG & C3 +++ C1q,C4 + Subendothelial deposits TYPE II Granular/linear;C3 No C1q,C4 Dense deposits Membranous nephropathy Granular;IgG & C3; diffuse Subepithelial deposits FSGS Focal;IgM & C3 Loss of foot processes & epithelial denudation IgA Nephropathy IgA, C3 & Properdin +/-IgG,IgM In mesengium Mesangial deposits
- 57. Major Glomerular pattern and differential diagnosis on light microscopy Minimal changes FSGS MESANGIAL HYPERCELLU LARITY Thick loops Tram loops proliferative cresents Nodular patte Minimal change disease Primary NOS IgA-HSP, MCD/FSGS Membraneo us MPGN Post infectious GN Pauci-immune Diabetes Thin membrane disease Secondary NOS Lupus diabetes HSP Lupus Anti GBM MPGN Early lupus Cellular type IgM nephropathy Diabetes Lupus HSP Lupus Amyloidosis Early/mid IgA Perihilar Tip lesion C1q nephropathy Alport collapsing C3 glomerulopa thy Amyloidosis
- 58. DIABETIC Nephropathy: Diabetic glomeruloscerosis - Thickening of the basement membranes - Mesangial matrix accumulation - Mesangial nodules - Capsular drop - Fibrin cap Tubular atrophy & interstitial fibrosis Afferent & efferent arteriolar hyalinosis Arteriosclerosis
- 59. Capillary walls continue to thicken Mesangial volume continues to increase Development of mesangial nodules Kimmelsteil-Wilson type Nodular form
- 60. Fibrin cap Capsular drop
- 61. Pathological diagnosis of Interstitial diseases : Interstitial expansion by edema : • ATN • Renal vein Thrombosis • Nephrotic syndrome (MCD) • Thrombotic microangiopathy Interstitial expansion by eosinophilic material : • Collagen-fibrosis • Sickle cell disease • Radiation nephritis • Amyloidosis
- 62. Interstitial expansion by leukocytes : • Polymorphs (APSGN, drug induced, sepsis) • Lymphoplasmacytic (Chronic nephritis, vasculitis, rejection) • Eosinophilis (Vasculitis, drug induced, lupus) • Epitheloid (TB, Sarcoidosis, drug induced, Malakoplakia) Expansion by foam cells : • Alport’s syndrome • Membranous GN Interstitial haemorrhage : • Acute rejection • Malignant HTN • Vasculitis
- 63. Interstitial expansion by neoplastic cells : • Lymphoma/Leukemia • Primary renal cell carcinoma • Metastasis Crystals & mineral deposits : • Nephrocalcinosis Calcium carbonate • Acute renal failure Calcium oxalate • Gout Uric acid • Glomerular disease with Nephrotic syndrome Cholesterol
- 64. The main injuries of vascular elements are : Vasculitis • Systemic injury • Local injury - due to toxins, infection, inflammation Deposition of materials • Amyloidosis • Immune complexes • Arteriosclerosis
- 65. Hypertension induced injuries • Hypertrophy of media • Intimal thickening • Fibrinoid necrosis • Thrombotic microangiopathy • Fibrointimal hyperplasia Endothelitis • Drug induced • Toxins
- 66. RENAL MASSES: • Biopsy is usually avoided • The findings are unlikely to change management and there is a risk of dissemination of cancer along the biopsy track • Biopsy may be considered if there is disseminated neoplasia to see whether there is a primary malignant neoplasm in the kidney, or whether the renal mass is a metastasis. *Renal tissue sampling for renal neoplasms commonly include: – Needle biopsies and – Fine needle aspirates. – They are performed prior to percutaneous ablation ( radio or cryotherapy ) of the mass or other clinical entities like lymphoma or metastasis. – The cores are usually processed for routine H&E stained slide. – *Immunohistochemistry may aid in typing.
- 67. FUTURE DIRECTIONS: – Currently nephrology practice uses percutaneous kidney biopsy to diagnose kidney disease with the hopes of providing therapeutic and prognostic information that can alter disease progression. – Precision medicine as it pertains to nephrology can expand the role of kidney biopsy and provide a patient with a personalized disease profile and targeted therapy. – It relies on the integration of techniques, including genomics and proteomics to extract molecular diagnostic information from kidney tissue, blood and urine samples and allowing for the identification of disease specific biomarkers. – The information gained from ongoing trials over subsequent decades may allow nephrologists to take a targeted approach towards the treatment of these heterogenous disease states.
- 68. TAKE HOME MESSAGE • Kidney biopsy is an indispensable tool for current practice of evidence- based medicine • The clinicopathological correlation is a great challenge for both pathologists and nephrologists • LM, IF, and EM should be done routinely in all biopsies if possible. • Kidney biopsy, appropriately processed and interpreted, will yield the correct clinicopathological diagnosis, leading to the appropriate therapeutic strategy while, at the same time, providing key prognostic information
- 69. THANK YOU
Editor's Notes
- #42: BM+meseng