OS 214 [A]: Digestive and Excretory Lab 01.3: Lab Skills Session – Case 2 Dr. Sonia L. Chicano March 12, NIKA, ADA, GUDO

History and PE 68/F, known diabetic, presenting with a 5- mo history of hyperpigmented patches on both LE She later developed grade 3 bipedal edema, frothy urine, occasional tea- colored urine, and right flank pain. NIKA, ADA, GUDO Lab 01.3: Lab Skills Session – Case 2

Work-Up Work-ups revealed consistent hematuria on urinalysis but with (-) dysmorphic RBCs. Proteinuria was in the nephrotic range, and serum creatinine was 188. She was started on enalapril and losartan for proteinuria, and she was admitted for kidney biopsy. ANA (+), normal C3 NIKA, ADA, GUDO Lab 01.3: Lab Skills Session – Case 2

No mesangial and endothelial proliferation

Segmental sclerosis (-) Mesangial and endothelial proliferation Thin and delicate capillary loops (normal) Silver stain*

Silver stain Segmental sclerosis

What’s the pattern? For case 2: 27 glomeruli –10 global sclerosis –1 segmental sclerosis 1 out of 27  Focal segmental glomerulosclerosis (FSGS) NIKA, ADA, GUDO Lab 01.3: Lab Skills Session – Case 2

Global sclerosis

Tubular atrophy Collagen deposition in Bowman’s space, not crescent*

Colloid casts* Inflammatory interstitial infiltrates Normal tubules

Inflammatory interstitial infiltrates H&E Colloid cast Arteriole

Calcification* inside a tubule

Global sclerosis (2) Colloid casts Tubular atrophy

Colloid cast Arterioles Tubular atrophy

Normal tubules

Masson Trichome Stain Fibrosis (blue green)

1+trace 1+ Trace-1+

5 4 1 – Mesangial cells 2 – Endothelial cell* 3 – Capillary loops 4 – Parietal epithelial cell 5 – Bowman’s capsule – Effaced foot processes

Capillary loop

No deposits in GBM Preserved endothelial fenestrations Effaced foot processes

No deposits in GBM Preserved endothelial fenestrations Effaced foot processes

1 – Nuclei of mesangial cells 2 – Cytoplasm of mesangial cells 3 – Mesangial matrix No mesangial deposits

Summary of Findings LM: FSGS IF: None EM: Foot process effacement NIKA, ADA, GUDO Lab 01.3: Lab Skills Session – Case 2

Diagnosis FSGS with 76% global GS (31/41 glomeruli) and 15% segmental GS (4/41 glomeruli) Moderate interstitial fibrosis and tubular atrophy R/O: 2º FSGS NIKA, ADA, GUDO Lab 01.3: Lab Skills Session – Case 2