1. Laboratory Handling of the Renal Biopsy Dr. Issam Francis Kuwait 4 th SSN Annual International Conference, Riyadh, April 2009

2. The Renal Biopsy Historical backgrounds 1934 Percutaneous kidney biopsy (tumors) 1951 first kidney biopsy for medical disease 1953 Introduced to US 1955 first renal clinicopathology working group Modern Times: Real-time ultrasound guidance Transjugular needle biopsy Spring-loaded biopsy gun CT-Guided biopsy EM IHC

6. Needle Biopsy Open Biopsy

9. The Renal Biopsy Laboratory handling EMParaffin Sections IF Under a stereomicroscope

10. The Renal Biopsy Laboratory handling EMParaffin Sections& IHC (no IF) Under a stereomicroscope

11. The Renal Biopsy Laboratory handling 1- fixation (Immediate): 10 % NB Formalin (paraffin sections) 4% Gluteraldehyde (EM) No fixation(Immunofluorescence) 2- Paraffin sections cut at 3 u thickness 3- Stains: HE PAS GMS TC CR ….. HEPASGMSHETCHEPASGMSHE TC HEHEPASGMSHETC PASGMS HETC (CR, Microbial stains, others.) 4- Immunohistochemistry (IG, C, other antigens) 5- Immunofluorescence (IG, C)

12. The Renal Biopsy Laboratory handling HE PAS JNS TC HE PAS JNS TC 3-4 microns 24 Sections Extra sectons for CR, Microbial stains, IHC etc.

14. 14 The Renal Biopsy Laboratory handling Biopsy adequacy: – Cortex and medulla – 1-2 glomeruli EM – 3-5 glomeruli IF – 6 glomeruliPS (native kidney) – 10 glomeruliPS (renal allograft)

15. The Renal Biopsy Manual vs. automated

16. Biopsy Fixation 10% Neutral Buffered Formalin Solution: Why? 1.Cheap 2.Commonly available 3.Suitable for: – All histological stains – Immunohistological methods (not IF) 4.Reversible: Possible to transfer to another fixative for electron microscopy.

17. Morphological examination: 1.Glomeruli 2.Tubules 3.Interstitium 4.Blood vessels Renal Biopsy Morphological Examination

18. Primary Site of Renal Pathology Glomerulus Glomerular pathology: – Inflammation – GBM changes – Scarring – Abnormal deposits – Cellularity Tubules Tubular pathology : – Cellular injury – Regeneration – Atrophy – Casts Interstitium Interstitial pathology: – Cellular infiltrates – Edema/fibrosis Vascular disease Vascular pathology: – Inflammation – Sclerosis – Hyalinosis – Thrombosis ? Stain

19. Activity of disease: Cellular proliferation Crescent formation Necrotizing lesions Inflammation Chronicity of disease : Tubular atrophy Fibrosis Vascular sclerosis Renal pathology report Disease Stage

20. The Renal Biopsy Stains 1.HE General 2.PASBasement M. & Mesangial matrix 3.TrichromeFibrosis 4.SilverBasement M. & Mesangial matrix 5.Congo redAmyloid 6.MSBFibrin

24. 24

38. Masson’s trichrome

39. Structure/ComponentPASJonesMasson’s trichrome Basement membraneRed BlackDeep blue Mesangial matrixRedBlackDeep blue Interstitial collagenNegative Pale blue Cell cytoplasm (normal)Negative (most)NegativeRust/orange Immune complexNegative Bright red AmyloidNegative Light blue Tubular castsRedGray to blackLight blue Staining characteristics of selected normal and abnormal renal structures

40. SATINING OF RENAL TISSUE COMPONENTS FEATUREHEPASTRICHROMEJONES/GMS CellularityExcellent Poor Mesangial MPoorExcellentVariableExcellent Glom. SclerosisPoorExcellent Good Immune Cox.Poor VariableNegative Basement M.PoorExcellentGoodExcellent FibrosisPoor Excellent Vascular hyalineGoodPoorGoodNegative ThrombiGoodPoorGoodVariable

41. 41 H&E Amyloid: Silver negative 8 micron sections

42. 42 Congo Red

43. Fibrillary GP

44. Diagnoses overlooked without IHC 1.Light chain-associated diseases 2.AL amyloid 3.Monoclonal immunoglobulin deposition disease 4.Light chain cast nephropathy 5.IgA nephropathy/Henoch–Shonlein purpura 6.IgM nephropathy 7.C1q nephropathy 8.Antiglomerular basement membrane disease 9.Humoral (C4d) transplant rejection 10.Fibronectin glomerulopathy

45. IgG

46. IgA

47. Electron microscopic helpful, but not usually essential for the diagnosis 1. Nephrotic syndrome 2. Acute renal failure 3. Chronic renal failure 4. Renal disease in diabetes mellitus 5. Renal disease in SLE 6. Suspected rejection of a renal allograft 7. Repeat specimen when the diagnosis has been made

48. Electron microscopy is most likely to help 1. Microscopic Hematuria with normal renal function 2. Family history of renal disease. 3. Asymptomatic proteinuria with normal renal function.

49. Diagnoses overlooked without EM 1.Fibrillary /immunotactoid glomerulopathy 2.Nail–patella syndrome 3.Lipoprotein glomerulopathy 4.Dense deposit disease 5.Alport’s syndrome 6.Thin basement membrane nephropathy 7.Collagenofibrotic glomerulopathy

50. Thank You