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Renal Ultrastructural Pathology Lecture 3 T - V

Basic Renal EM workshop Southampton September 30 th 2011. Renal Ultrastructural Pathology Lecture 3 T - V. Bart E Wagner BSc CSc FIBMS Dip Ult Path Chief Biomedical Scientist Electron Microscopy Section Histopathology Department Northern General Hospital Sheffield

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Renal Ultrastructural Pathology Lecture 3 T - V

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  1. Basic Renal EM workshop Southampton September 30th 2011 Renal Ultrastructural PathologyLecture 3 T - V Bart E Wagner BSc CSc FIBMS Dip Ult Path Chief Biomedical Scientist Electron Microscopy Section Histopathology Department Northern General Hospital Sheffield South Yorkshire UK S5 7AU bart.wagner@sth.nhs.uk Tel+44(0)114-27 14154 Histopathology Department Northern General Hospital

  2. Renal ultrastructural pathologyLecture 3 - Topics Transplant – Hyperacute rejection Transplant – Acute cellular rejection Transplant – Chronic Humoral rejection Transplant – Calcineurin inhibitor (CNI) toxicity Vasculopathy Viral infection

  3. TransplantHyperacute rejection 4

  4. TransplantHyperacute rejection • Caused by putting a kidney into a person with high titre preformed antibodies, such as acquired following a previously rejected kidney • Biopsy taken 30 minutes post vascular anastamosis • Appearance similar to disseminated intravascular coagulation (DIC) • Numerous intraglomerular platelet and fibrin thrombi • Haemorrhagic infarcted kidney removed next day

  5. Protocol post-perfusion biopsy Numerous thrombosed capillary loops

  6. Filled with fibrin tactoids

  7. Necrotic endothelial cell nucleus Aggregate of degranulated and non-degranulated platelets

  8. Transplant Acute cellular rejection 5

  9. Glomerulitis Interstitial oedema

  10. Glomerulitis or intraglomerular endothelialitis Higher magnification of previous slide Numerous intracapillary mononuclear cells

  11. Apoptotic lymphocyte

  12. Filopodia Dendritic cell

  13. Antigen in exosomes (endosomal vesicles)

  14. Endothelialitis of peritubular capillary (PTC)

  15. Tubulitis

  16. Tubulitis Higher magnification of previous slide

  17. Disruption of tubular basement membrane

  18. TransplantChronic humoral rejection (CHR)

  19. TransplantChronic Humoral Rejection • C4D staining of vessel walls by immunoperoxidase or fluorescence • Basement membrane multilayering in glomerularsubendothelial zone by endothelial cells producing multiple new basement membranes • In excess of 6 layers of new basement membrane around peritubular capillaries

  20. New basement membrane laid down by endothelial cells Mesangial cell interpositioning

  21. Peritubular capillary (PTC) basement membrane multilayering

  22. Peritubular capillary basement membrane multilayering

  23. Transplant cyclosporinetoxicityLung transplant patient 7

  24. Transplant Cyclosporine A toxicity • Lung transplant patient • Iatrogenic acute renal failure • Biopsied for prognostic reasons • Calcineurin inhibitor (CNI) toxicity

  25. Fine isometric vacuolation Arteriolar hyalinosis

  26. Swollen lysosomes in distal convoluted tubule

  27. Fine isometric vacuolation distal convoluted tubular cells

  28. Higher magnification of previous slide These changes can be seen in fibroblast lysosomes in renal transplant biopsies Lysosomal enzymes displaced peripherally

  29. Proximal convoluted tubular cells Isometric vaculation

  30. Higher magnification of previous slide Diffusely swollen lysosomes

  31. Hydropically swollen lysosomes have also been seen in: • Muscle biopsy in patient given colloid. J Hepatol 1986;3:223-227 • Skin biopsy in patient given amphipathic antibiotics. Personal observation G Mierau, Denver. • Skin biopsy pre-treated with topical local anaesthetic. J Inherit Metab 27 (2004) 507-511 • On seeing the expanded lysosomes, I initially thought they might be cases of unsuspected lysosomal storage disorder. • i.e. Pseudo lysosomal storage.

  32. Vasculopathy 8

  33. Chronic hypertensive elastic reduplication and lumen narrowing

  34. Hypertensive arteriolar hyalinosis

  35. Malignant phase hypertension Extravasation of erythrocytes Fibrinoid necrosis of vessel wall

  36. Viral infectionBK polyoma

  37. Distal convoluted tubule intranuclear inclusion

  38. Higher magnification of previous slide

  39. Intranuclear inclusion formed of numerous polyoma virus particles Higher magnification of previous slide

  40. CytomegalovirusCMV Transplant kidney

  41. Case from Dr Michael Mengel, Greifswald, Germany. With permission.

  42. Case from Dr Michael Mengel, Greifswald, Germany. Nucleus not in plane of section Intracytoplasmic vesicles filled with virions

  43. CMV Liver biopsy

  44. Liver biopsy. CMV in intraportal tract bile duct cholagiocyte

  45. CMV in liver biopsy ‘Owls eye’ intranuclear inclusion

  46. Higher magnification of previous slide Intracytoplasmic vesicles filled with typical herpes group virions

  47. Final comments • Do toluidine blues on all biopsies and add description to light microscopy report. • When choosing which block to cut thin sections off, choose the one with glomeruli that are neither completely normal nor sclerosed, and has the most glomeruli, but not one with GBM wrinkling. • Either, do EM on all renal biopsies, in which case expect to be confirmatory in 50% of cases, and to change diagnosis partially in 25%, and completely in 25%. • Or, if being selective as to which cases should do EM on, should be done on 60% of cases. • As for which cases to choose: heavy proteinuria, uncertainly of diagnosis, unexpected findings on light microscopy immunofluorescence or resin sections, clinicopathological miss-match. • If having difficulty in interpreting EM findings:HAVE A LOOK AT ANOTHER GLOMERULUS. • If requesting a second opinion, send with clinical details, histology and IF report, and EM images in step magnifications.

  48. I hope you enjoy these lectures.You are more than welcome to use these images for your own lecture purposes, with acknowledgement – but I’d rather you didn’t use them for publication, in print or on a web site, without checking with me first.If you have any diagnostic EM related queries do contact me on bart.wagner@sth.nhs.ukand I’d be happy to try to help you out. Bart Wagner

  49. Don’t forget the group photo! 1996

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