Renal Ultrastructural PathologyRenal Ultrastructural PathologyLecture 3 T - VLecture 3 T - V

Bart E Wagner Bart E Wagner BSc CSc FIBMS Dip Ult PathBSc CSc FIBMS Dip Ult Path

Chief Biomedical ScientistChief Biomedical ScientistElectron Microscopy SectionElectron Microscopy SectionHistopathology DepartmentHistopathology DepartmentNorthern General HospitalNorthern General Hospital

SheffieldSheffieldSouth YorkshireSouth Yorkshire

UKUKS5 7AUS5 7AU

bart.wagner@sth.nhs.ukTel+44(0)114-27 14154Tel+44(0)114-27 14154

Basic Renal EM workshop

Southampton

September 30th 2011

Histopathology DepartmentNorthern General Hospital

Renal ultrastructural pathologyRenal ultrastructural pathologyLecture 3 - TopicsLecture 3 - Topics

1.1. Transplant – Hyperacute rejectionTransplant – Hyperacute rejection

2.2. Transplant – Acute cellular rejectionTransplant – Acute cellular rejection

3.3. Transplant – Chronic Humoral rejectionTransplant – Chronic Humoral rejection

4.4. Transplant – Calcineurin inhibitor (CNI) toxicityTransplant – Calcineurin inhibitor (CNI) toxicity

5.5. VasculopathyVasculopathy

6.6. Viral infectionViral infection

TransplantTransplant

Hyperacute rejectionHyperacute rejection

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TransplantTransplant

Hyperacute rejectionHyperacute rejectionCaused by putting a kidney into a person with high titre preformed Caused by putting a kidney into a person with high titre preformed antibodies, such as acquired following a previously rejected kidneyantibodies, such as acquired following a previously rejected kidney

Biopsy taken 30 minutes post vascular anastamosisBiopsy taken 30 minutes post vascular anastamosis

Appearance similar to disseminated intravascular coagulation (DIC)Appearance similar to disseminated intravascular coagulation (DIC)

Numerous intraglomerular platelet and fibrin thrombiNumerous intraglomerular platelet and fibrin thrombi

Haemorrhagic infarcted kidney removed next dayHaemorrhagic infarcted kidney removed next day

Numerous thrombosed capillary loops

Protocol post-perfusion biopsy

Filled with fibrin tactoids

Necrotic endothelial cell nucleus

Aggregate of degranulated and non-degranulated platelets

Transplant Transplant

Acute cellular rejectionAcute cellular rejection

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Glomerulitis

Interstitial oedema

Glomerulitis or intraglomerular endothelialitis

Higher magnification of previous slide Numerous intracapillary mononuclear cells

Apoptotic lymphocyte

Dendritic cell

Filopodia

Antigen in exosomes (endosomal vesicles)

Endothelialitis of peritubular capillary (PTC)

Tubulitis

TubulitisHigher magnification of previous slide

Disruption of tubular basement membrane

TransplantTransplant

Chronic humoral rejection Chronic humoral rejection (CHR)(CHR)

TransplantTransplantChronic Humoral RejectionChronic Humoral Rejection

C4D staining of vessel walls by immunoperoxidase or fluorescenceC4D staining of vessel walls by immunoperoxidase or fluorescence

Basement membrane multilayering in glomerular subendothelial Basement membrane multilayering in glomerular subendothelial zone by endothelial cells producing multiple new basement zone by endothelial cells producing multiple new basement membranesmembranes

In excess of 6 layers of new basement membrane around In excess of 6 layers of new basement membrane around peritubular capillariesperitubular capillaries

New basement membrane laid down by endothelial cells

Mesangial cell interpositioning

Peritubular capillary (PTC) basement membrane multilayering

Peritubular capillary basement membrane multilayering

Transplant cyclosporine toxicityTransplant cyclosporine toxicity

Lung transplant patientLung transplant patient

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Transplant Transplant Cyclosporine A toxicityCyclosporine A toxicity

Lung transplant patientLung transplant patient

Iatrogenic acute renal failureIatrogenic acute renal failure

Biopsied for prognostic reasonsBiopsied for prognostic reasons

Calcineurin inhibitor (CNI) toxicityCalcineurin inhibitor (CNI) toxicity

Arteriolar hyalinosis

Fine isometric vacuolation

Swollen lysosomes in distal convoluted tubule

Fine isometric vacuolation distal convoluted tubular cells

Higher magnification of previous slide

Lysosomal enzymes displaced peripherally These changes can be seen in fibroblast lysosomes in renal transplant biopsies

Proximal convoluted tubular cells

Isometric vaculation

Higher magnification of previous slide

Diffusely swollen lysosomes

Hydropically swollen lysosomes have also Hydropically swollen lysosomes have also been seen in:been seen in:

Muscle biopsy in patient given colloid. Muscle biopsy in patient given colloid. J J

Hepatol 1986;3:223-227Hepatol 1986;3:223-227

Skin biopsy in patient given amphipathic antibiotics. Skin biopsy in patient given amphipathic antibiotics. Personal Personal

observation G Mierau, Denver. observation G Mierau, Denver.

Skin biopsy pre-treated with topical local anaesthetic. Skin biopsy pre-treated with topical local anaesthetic. J J

Inherit Metab 27 (2004) 507-511Inherit Metab 27 (2004) 507-511

On seeing the expanded lysosomes, I initially thought they On seeing the expanded lysosomes, I initially thought they might be cases of unsuspected lysosomal storage might be cases of unsuspected lysosomal storage disorder. disorder.

i.e. Pseudo lysosomal storage.i.e. Pseudo lysosomal storage.

VasculopathyVasculopathy

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Chronic hypertensive elastic reduplication and lumen narrowing

Hypertensive arteriolar hyalinosis

Fibrinoid necrosis of vessel wall

Extravasation of erythrocytes

Malignant phase hypertension

Viral infectionViral infectionBK polyomaBK polyoma

Distal convoluted tubule intranuclear inclusion

Higher magnification of previous slide

Higher magnification of previous slide

Intranuclear inclusion formed of numerous polyoma virus particles

CytomegalovirusCMV

Transplant kidney

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

Nucleus not in plane of section Intracytoplasmic vesicles filled with virions

Case from Dr Michael Mengel, Greifswald, Germany.

CMV CMV

Liver biopsyLiver biopsy

Liver biopsy. CMV in intraportal tract bile duct cholagiocyte

CMV in liver biopsy

‘Owls eye’ intranuclear inclusion

Higher magnification of previous slide

Intracytoplasmic vesicles filled with typical herpes group virions

Final commentsFinal commentsDo toluidine blues on all biopsies and add description to light microscopy Do toluidine blues on all biopsies and add description to light microscopy report.report.

When choosing which block to cut thin sections off, choose the one with 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 that are neither completely normal nor sclerosed, and has the most glomeruli, but not one with GBM wrinkling.glomeruli, but not one with GBM wrinkling.

Either, do EM on all renal biopsies, in which case expect to be confirmatory in 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 50% of cases, and to change diagnosis partially in 25%, and completely in 25%.25%.

Or, if being selective as to which cases should do EM on, should be done on Or, if being selective as to which cases should do EM on, should be done on 60% of cases. 60% of cases.

As for which cases to choose: heavy proteinuria, uncertainly of diagnosis, As for which cases to choose: heavy proteinuria, uncertainly of diagnosis, unexpected findings on light microscopy immunofluorescence or resin sections, unexpected findings on light microscopy immunofluorescence or resin sections, clinicopathological miss-match. clinicopathological miss-match.

If having difficulty in interpreting EM findings:If having difficulty in interpreting EM findings: HAVE A LOOK AT ANOTHER GLOMERULUSHAVE A LOOK AT ANOTHER GLOMERULUS..

If requesting a second opinion, send with clinical details, histology and IF If requesting a second opinion, send with clinical details, histology and IF report, and EM images in step magnificationsreport, and EM images in step magnifications. .

I hope you enjoy these lectures.I hope you enjoy these lectures.

You are more than welcome to use these images for your own lecture purposes, with 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 acknowledgement – but I’d rather you didn’t use them for publication, in print or on a web site, without

checking with me first.checking with me first.If you have any diagnostic EM related queries do contact me on If you have any diagnostic EM related queries do contact me on bart.wagner@sth.nhs.uk

and I’d be happy to try to help you out. and I’d be happy to try to help you out.

Bart WagnerBart Wagner

Don’t forget the group photo!

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