1. OS 214 [A]: Digestive and Excretory Lab 01.3: Lab Skills Session – Case 2 Dr. Sonia L. Chicano March 12, 2014 2 NIKA, ADA, GUDO

2. 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

3. 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

4. No mesangial and endothelial proliferation

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

6. Silver stain Segmental sclerosis

7. 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

8. Global sclerosis

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

10. Colloid casts* Inflammatory interstitial infiltrates Normal tubules

11. Inflammatory interstitial infiltrates H&E Colloid cast Arteriole

12. Calcification* inside a tubule

13. Global sclerosis (2) Colloid casts Tubular atrophy

14. Colloid cast Arterioles Tubular atrophy

15. Normal tubules

16. Masson Trichome Stain Fibrosis (blue green)

17. 1+trace 1+ Trace-1+

18. 5 4 1 – Mesangial cells 2 – Endothelial cell* 3 – Capillary loops 4 – Parietal epithelial cell 5 – Bowman’s capsule – Effaced foot processes 2 3 1 1 3

19. Capillary loop

20. No deposits in GBM Preserved endothelial fenestrations Effaced foot processes

21. No deposits in GBM Preserved endothelial fenestrations Effaced foot processes

23. 1 – Nuclei of mesangial cells 2 – Cytoplasm of mesangial cells 3 – Mesangial matrix 2 1 1 2 3 No mesangial deposits

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

25. 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