the need of electron microscopy in kidney biopsy diagnosis yrjö collan, md, dr. med.sci., frcpath...
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The need of electron microscopy in kidney biopsy diagnosis
The need of electron microscopy in kidney biopsy diagnosis
Yrjö Collan, MD, Dr. Med.Sci., FRCPath
Department of Pathology, University of Turku, Finland, and the International University Program,
Turku, Finland
Yrjö Collan, MD, Dr. Med.Sci., FRCPath
Department of Pathology, University of Turku, Finland, and the International University Program,
Turku, Finland
Elements of the kidney biopsy study in a histopathology laboratory
Elements of the kidney biopsy study in a histopathology laboratory
Traditional light microscopy: thin section, a number of stains including H&E, PAS, silver methenamine, Congo red, Masson´s trichrome.
Immunofluorescence (IF) or other immunomicroscopy including staining for IgG, IgA, IgM, fibrinogen, C1q, kappa and lambda chains
Electron microscopy, glutaraldehyde fixation, osmium tetroxide treatment, plastic embedding, ultrathin sections, staining of sections, study in an electron microscope
Traditional light microscopy: thin section, a number of stains including H&E, PAS, silver methenamine, Congo red, Masson´s trichrome.
Immunofluorescence (IF) or other immunomicroscopy including staining for IgG, IgA, IgM, fibrinogen, C1q, kappa and lambda chains
Electron microscopy, glutaraldehyde fixation, osmium tetroxide treatment, plastic embedding, ultrathin sections, staining of sections, study in an electron microscope
Evaluation of a study elementEvaluation of a study element
Kidney biopsy diagnosis is a complicated decision process and includes the element of uncertainty
To decrease the influence of uncertainty many methods are used in the study of biopsies and the clinical data are carefully associated with the elements of the biopsy study: the whole picture matters.
Evaluation of an individual element can be done by excluding the element from the decision process, and looking how much the exclusion influences the final diagnosis or uncertainties associated with it
Kidney biopsy diagnosis is a complicated decision process and includes the element of uncertainty
To decrease the influence of uncertainty many methods are used in the study of biopsies and the clinical data are carefully associated with the elements of the biopsy study: the whole picture matters.
Evaluation of an individual element can be done by excluding the element from the decision process, and looking how much the exclusion influences the final diagnosis or uncertainties associated with it
The categories of EM contribution to diagnosis
The categories of EM contribution to diagnosis
Generally authors have found suitable to divide the potential contribution in 3 categories:
1. EM is absolutely necessary for final diagnosis 2. EM has supporting influence to final diagnosis,
clarifiyng remaining uncertanties 3. EM appears redundant, i.e. with no influence on final
diagnosis or associated uncertainties
We cannot decide about the category if EM has not been done.
Generally authors have found suitable to divide the potential contribution in 3 categories:
1. EM is absolutely necessary for final diagnosis 2. EM has supporting influence to final diagnosis,
clarifiyng remaining uncertanties 3. EM appears redundant, i.e. with no influence on final
diagnosis or associated uncertainties
We cannot decide about the category if EM has not been done.
Revising the diagnosis by re-embedding in plastic
Revising the diagnosis by re-embedding in plastic
Collan Y, Klockars M, Heino M: Revision of light-microscopic kidney biopsy diagnosis in glomerular disease. Nephron 20: 24-31, 1978
18 paraffin embedded biopsies of 1967, positive LM evidence of glomerular disease in 9/18. After re-embedding in Epon, positive EM evidence of glomerular disease in 18/18 cases. Also 1 micron thick plastic sections of the re-embedded biopsies had higher fraction of positive cases than 4 micron thick paraffin embedded biopsies alone.
Collan Y, Klockars M, Heino M: Revision of light-microscopic kidney biopsy diagnosis in glomerular disease. Nephron 20: 24-31, 1978
18 paraffin embedded biopsies of 1967, positive LM evidence of glomerular disease in 9/18. After re-embedding in Epon, positive EM evidence of glomerular disease in 18/18 cases. Also 1 micron thick plastic sections of the re-embedded biopsies had higher fraction of positive cases than 4 micron thick paraffin embedded biopsies alone.
Conclusion from 1978Conclusion from 1978
Improved resolution improves the reliability of diagnosis
Re-embedding in plastic may be helpful Spargo (Human Pathol 6:405, 1975) also
gave positive evaluation of the role of EM, Muehrke et al. (Arch Intern Med 124:170, 1969) had been more reserved
Improved resolution improves the reliability of diagnosis
Re-embedding in plastic may be helpful Spargo (Human Pathol 6:405, 1975) also
gave positive evaluation of the role of EM, Muehrke et al. (Arch Intern Med 124:170, 1969) had been more reserved
For thin BM nephropathy re-embedding in plastic is not the best solution
For thin BM nephropathy re-embedding in plastic is not the best solution
Nasr SH, Markowitz GS, Valeri AM, Yu Z, Chen L, D´Agati VD (Columbia Univ, New York, USA): Thin BM nephropathy (TBMN) cannot be diagnosed reliably in deparaffinized, formalin fixed tissue. Nephrol Dial Transplant 22:1228-1232, 2007
Shrinkage during the process, reflected in a GBM thickness decrease of about 30%
Nasr SH, Markowitz GS, Valeri AM, Yu Z, Chen L, D´Agati VD (Columbia Univ, New York, USA): Thin BM nephropathy (TBMN) cannot be diagnosed reliably in deparaffinized, formalin fixed tissue. Nephrol Dial Transplant 22:1228-1232, 2007
Shrinkage during the process, reflected in a GBM thickness decrease of about 30%
Criteria for diagnosis of thin BM nephropathy
Criteria for diagnosis of thin BM nephropathy
Haas M: Arch Pathol Lab Med 130: 699-706, 2006
Haas M: Arch Pathol Lab Med 130: 699-706, 2006
Conclusion on re-embedding in plastic
Conclusion on re-embedding in plastic
To get the best material for EM studies you cannot rely on re-embedding
You have to try to get plastic embedded material for EM already at the early phase of the handling of the kidney biopsy
To get the best material for EM studies you cannot rely on re-embedding
You have to try to get plastic embedded material for EM already at the early phase of the handling of the kidney biopsy
Pearson et al. 1994Pearson et al. 1994
Pearson JM, McWilliam LJ, Coyne JD, Curry A: Value of electron microscopy in the diagnosis of renal disease. J Clin Pathol 47: 126-128, 1994 (GB)
EM valuable in about 75%, essential in about 25%, irrelevant in 25%
Pearson JM, McWilliam LJ, Coyne JD, Curry A: Value of electron microscopy in the diagnosis of renal disease. J Clin Pathol 47: 126-128, 1994 (GB)
EM valuable in about 75%, essential in about 25%, irrelevant in 25%
Haas 1997 Haas 1997
A reevaluation of routine electron microscopy in the examination of native renal biopsies. J Am Soc Nephrol 8: 70-76, 1997 (USA)
EM valuable in about 50% of biopsies However, of all biopsies, material should be
embedded in plastic to solve uncertainties
A reevaluation of routine electron microscopy in the examination of native renal biopsies. J Am Soc Nephrol 8: 70-76, 1997 (USA)
EM valuable in about 50% of biopsies However, of all biopsies, material should be
embedded in plastic to solve uncertainties
Herrera´s group 1997-2002-Herrera´s group 1997-2002-
Gu X, Herrera GA: The value of electron microscopy in the diagnosis of IgA nephropathy. Ultrastruct Pathol 26:203-210, 2002 (USA)
Herrera GA: The value of electron microscopy in the diagnosis and clinical management of lupus nephritis. Ultrastruct Pathol 23: 63-77, 1999 (USA)
Herrera GA, Isaac J, Turbat-Herrera EA: Role of electron microscopy in transplant renal biopsies. Ultrastruct Pathol 21:481-498, 1997 (USA)
In general EM is valuable, especially in transplant biopsies
Gu X, Herrera GA: The value of electron microscopy in the diagnosis of IgA nephropathy. Ultrastruct Pathol 26:203-210, 2002 (USA)
Herrera GA: The value of electron microscopy in the diagnosis and clinical management of lupus nephritis. Ultrastruct Pathol 23: 63-77, 1999 (USA)
Herrera GA, Isaac J, Turbat-Herrera EA: Role of electron microscopy in transplant renal biopsies. Ultrastruct Pathol 21:481-498, 1997 (USA)
In general EM is valuable, especially in transplant biopsies
Wang et al. 1998Wang et al. 1998
Wang S, Zhang Y, Zou W: The evaluation of electron microscopy in the pathological diagnosis of renal biopsies. Zhonghua Yi Xue Za Zhi 78: 782-784, 1998 (China)
777 biopsies, EM considered valuable in 32% (about 1/3 of the biopsies)
Wang S, Zhang Y, Zou W: The evaluation of electron microscopy in the pathological diagnosis of renal biopsies. Zhonghua Yi Xue Za Zhi 78: 782-784, 1998 (China)
777 biopsies, EM considered valuable in 32% (about 1/3 of the biopsies)
Collan et al. 2005Collan et al. 2005
Collan Y, Hirsimäki P, Aho H, Wuorela M, Sundstrom J, Tertti R, Metsarinne K: Value of electron microscopy in kidney biopsy diagnosis. Ultrastruct Pathol29:461-468, 2005 (Finland)
85 biopsies 71 nontransplnts
Essential 15.3 % 18.3
Additional info 58.8 % 53.5
No extra value 25.9 % 28.2
- Results in line with those of Pearson et al. (1994)
Collan Y, Hirsimäki P, Aho H, Wuorela M, Sundstrom J, Tertti R, Metsarinne K: Value of electron microscopy in kidney biopsy diagnosis. Ultrastruct Pathol29:461-468, 2005 (Finland)
85 biopsies 71 nontransplnts
Essential 15.3 % 18.3
Additional info 58.8 % 53.5
No extra value 25.9 % 28.2
- Results in line with those of Pearson et al. (1994)
Wagrowska-Danilowicz & Danilowicz 2007
Wagrowska-Danilowicz & Danilowicz 2007
Wagrowska-Danilowicz M, Danilowicz M: Current position of EM in diagnosis of glomerular disease. Pol J Pathol58:87-92, 2007
EM essential 35 (31.0 %) EM important 15 (13.3%) EM not needed 63 (55.7%)Conclusion: EM of value in 44.3%
Wagrowska-Danilowicz M, Danilowicz M: Current position of EM in diagnosis of glomerular disease. Pol J Pathol58:87-92, 2007
EM essential 35 (31.0 %) EM important 15 (13.3%) EM not needed 63 (55.7%)Conclusion: EM of value in 44.3%
Mubarak & Kazi 2009Mubarak & Kazi 2009
Mubarak M, Kazi JI: Role of immunofluorescence and EM in the evaluation of renal biopsies in nephrotic syndrome in a developing country. Ultrastruct Pathol 33: 260-264, 2009 (Pakistan)
200 biopsies useful essential helpful
IF 100% 23.5% 71.5%
EM 95.5 43.0 51.5
Mubarak M, Kazi JI: Role of immunofluorescence and EM in the evaluation of renal biopsies in nephrotic syndrome in a developing country. Ultrastruct Pathol 33: 260-264, 2009 (Pakistan)
200 biopsies useful essential helpful
IF 100% 23.5% 71.5%
EM 95.5 43.0 51.5
Darouich et al. 2010Darouich et al. 2010
Darouich S, Goucha RL, Jaafoura MH, Moussa FB, Zekri S, Maiz HB: Value of electron microscopy in the diagnosis of glomerular diseases. Ultrastruct Pathol 34:49-61, 2010 (Tunisia)
52 biopsies, 20 examined with EM, 18 primary disease, 2 transplants. EM essential of helpful in 60%.
Darouich S, Goucha RL, Jaafoura MH, Moussa FB, Zekri S, Maiz HB: Value of electron microscopy in the diagnosis of glomerular diseases. Ultrastruct Pathol 34:49-61, 2010 (Tunisia)
52 biopsies, 20 examined with EM, 18 primary disease, 2 transplants. EM essential of helpful in 60%.
Elhefnawy 2011Elhefnawy 2011
Elhefnawy NG: Contribution of electron microscopy to the final diagnosis of renal biopsies in Egyptian patients. Pathol Oncol Res 17: 121-125, 2011
120 biopsies for primary diagnosis Hereditary OtherEM essential 100% 23.5% useful 41.7% unhelpful 33.0%
Elhefnawy NG: Contribution of electron microscopy to the final diagnosis of renal biopsies in Egyptian patients. Pathol Oncol Res 17: 121-125, 2011
120 biopsies for primary diagnosis Hereditary OtherEM essential 100% 23.5% useful 41.7% unhelpful 33.0%
ConclusionsConclusions
The importance of EM in kidney biopsy diagnosis has increased rather than decreased. Many studies now find that EM is valuable in about 2/3 of the cases. Differences in evaluation may be associated with the material studied, and local factors, including treatment.
For the best service to the patient guarantee the EM option
Training in EM should also be a part or at least an option in the education of pathologists
The importance of EM in kidney biopsy diagnosis has increased rather than decreased. Many studies now find that EM is valuable in about 2/3 of the cases. Differences in evaluation may be associated with the material studied, and local factors, including treatment.
For the best service to the patient guarantee the EM option
Training in EM should also be a part or at least an option in the education of pathologists
Pathologists and electron microscopy
Pathologists and electron microscopy
Furness PN, Boyd S: Electron microscopy and immunohistochemistry in the assessment of renal biopsy specimens: actual and optimal practice. J Clin Pathol 49:233-237, 1996
Only 4% never requested EM. On average on 74% of biopsies. Many (40%) would like to do EM more often. But the pressure at work and the distance to the EM unit!
Education and management should both be involved
Furness PN, Boyd S: Electron microscopy and immunohistochemistry in the assessment of renal biopsy specimens: actual and optimal practice. J Clin Pathol 49:233-237, 1996
Only 4% never requested EM. On average on 74% of biopsies. Many (40%) would like to do EM more often. But the pressure at work and the distance to the EM unit!
Education and management should both be involved
As Haas says itAs Haas says it
“Electron microscopy provides essential or helpful information to a substantial fraction of cases, and whether a biopsy will fall into the latter fraction is not apparent from the clinical history”
Haas M: Electron microscopy in renal biopsy interpretation - when and why we still need it. US Nephrology1:19-22, 2007
“Electron microscopy provides essential or helpful information to a substantial fraction of cases, and whether a biopsy will fall into the latter fraction is not apparent from the clinical history”
Haas M: Electron microscopy in renal biopsy interpretation - when and why we still need it. US Nephrology1:19-22, 2007
Diseases often needing EM (we are looking for signs of these)
Diseases often needing EM (we are looking for signs of these)
Alport and other hereditary nephropathies Cryoglobulinemic glomerulopathies Dense deposit disease (MPG type II) Early diabetic changes Fabry´s disease Recurrence of focal segmental sclerosis Immunotactoid nephropathy Staging membranous nephropathy Thin GBM nephropathy
Alport and other hereditary nephropathies Cryoglobulinemic glomerulopathies Dense deposit disease (MPG type II) Early diabetic changes Fabry´s disease Recurrence of focal segmental sclerosis Immunotactoid nephropathy Staging membranous nephropathy Thin GBM nephropathy
D´Agati et al. 2005D´Agati et al. 2005
D´Agati VD, Jennette JC, Silva FG: Non neoplastic kidney diseases. Atlas of nontumor pathology. Am Registry of Pathology 2005
EM not questioned Stress the evaluation of location and texture
of dense deposits of various kinds
D´Agati VD, Jennette JC, Silva FG: Non neoplastic kidney diseases. Atlas of nontumor pathology. Am Registry of Pathology 2005
EM not questioned Stress the evaluation of location and texture
of dense deposits of various kinds
A caseA case
10-year old boy. Macrocytic anemia, and proteinuria. EM of the kidney biopsy shows a few dense deposits in the GBM. Weak IgG deposition, but no complement deposition in immunofluorescence.
What condition? Not mentioned in many kidney biopsy books.
10-year old boy. Macrocytic anemia, and proteinuria. EM of the kidney biopsy shows a few dense deposits in the GBM. Weak IgG deposition, but no complement deposition in immunofluorescence.
What condition? Not mentioned in many kidney biopsy books.
Imerslund-Grasbeck syndrome 1Imerslund-Grasbeck syndrome 1
Hereditary condition. Starts at birth. Symptoms like in vitamin B12 deficiency. Cause: the ileal enterocyte receptor for the B12
and intrinsic factor complex is abnormal and the patients do not absorb vitamin B12.
The abnormal receptor is also found in the kidney, tubules and glomeruli.
Hereditary condition. Starts at birth. Symptoms like in vitamin B12 deficiency. Cause: the ileal enterocyte receptor for the B12
and intrinsic factor complex is abnormal and the patients do not absorb vitamin B12.
The abnormal receptor is also found in the kidney, tubules and glomeruli.
Imerslund-Grasbeck syndrome 2Imerslund-Grasbeck syndrome 2
Patients often have proteinuria, but not progressive
The protein abnormality in the glomeruli seems to bind IgG, which is found as weak deposition in immunofluorescence investigation, and also seen in EM as dark deposits either in the GBM or in subendothelial position.
No complement deposition is present.
Patients often have proteinuria, but not progressive
The protein abnormality in the glomeruli seems to bind IgG, which is found as weak deposition in immunofluorescence investigation, and also seen in EM as dark deposits either in the GBM or in subendothelial position.
No complement deposition is present.
Imerslund-Grasbeck syndrome 3Imerslund-Grasbeck syndrome 3
The genetic abnormality is found at chromosome 14, in which one of 2 protein genes, which are part of the receptor complex, is abnormal (cubilin gene CUBN or amnionless gene AMN).
The genetic abnormality is found at chromosome 14, in which one of 2 protein genes, which are part of the receptor complex, is abnormal (cubilin gene CUBN or amnionless gene AMN).
Imerslund-Grasbeck syndrome 4Imerslund-Grasbeck syndrome 4
References: Kidney biopsy findings: Collan Y, Lähdevirta J,
Jokinen EJ: Selective Vitamin B12 malabsorption with proteinuria. Renal biopsy study. Nephron 23:297-303, 1979
General: Grasbeck R: Imerslund-Grasbeck syndrome (selective vitamin B12 malabsorption with proteinuria). Orphanet J Rare Dis: 1:17, 2006
References: Kidney biopsy findings: Collan Y, Lähdevirta J,
Jokinen EJ: Selective Vitamin B12 malabsorption with proteinuria. Renal biopsy study. Nephron 23:297-303, 1979
General: Grasbeck R: Imerslund-Grasbeck syndrome (selective vitamin B12 malabsorption with proteinuria). Orphanet J Rare Dis: 1:17, 2006