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Kidney non-tumor

Primary glomerular diseases

Biopsy-general


Reviewers: Nikhil Sangle, M.D. (see Reviewers page)
Revised: 10 April 2012, last major update April 2012
Copyright: (c) 2003-2012, PathologyOutlines.com, Inc.

General
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● Helps establish diagnosis and determine prognostic factors for renal disorders and transplant recipients
● Needle core or open biopsies are relatively safe, and only rarely cause morbidity or mortality; outpatient complication rate is 8% (Clin Nephrol 2011;76:464)
● Also important for appropriate management of elderly and very elderly patients with kidney disease (Adv Chronic Kidney Dis 2012;19:61)
● Percutaneous ultrasound-guided renal biopsy is safe, reliable and effective in children; most common indication is steroid resistant, steroid dependent or frequent relapsing idiopathic nephrotic syndrome (Hippokratia 2011;15:258)
● Pathology should correlate complete clinical and laboratory information (using a clinical form is recommended) with light microscopy, immunofluorescence and electron microscopy; cannot diagnose certain diseases without immunofluorescence or EM (Mod Pathol 2004;17:1555)
● Must carefully evaluate glomeruli, tubules, interstitium and vessels

Procedure
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● Specimen must be handled gently
Donít: use forceps, pull or stretch tissue, place tissue on dry gauze or water-soaked gauze, freeze entire sample or place on ice-cold saline
Do: transport with tissue culture medium on saline-moistened gauze; cut with fresh scalpel
● Dissecting microscope helps assess adequacy of glomeruli; place sample on glass slide with saline
● Two cores recommended
Core #1: take samples 0.5 to 1.0 mm thick from each end with razor / scalpel and put in glutaraldehyde for EM; place remainder in saline, then fixative for light microscopy
Core #2: take samples for EM, snap freeze the remainder for immunofluorescence
● Wrap light microscopy specimens in lens paper prewetted with fixative (avoid sponges or plastic embedding bags)
● If only one core or a small specimen is obtained, use tissue for EM and immunofluorescence because EM semi-thin sections can also provide light microscopic information
Fixative: mercury fixatives (Zenkerís, Bouinís, other) provide optimal architectural and cytologic detail; ethanol fixation helps find glycogen or crystals of urate / uric acid
● Recommended to section through entire specimen, put 3-4 sections on each slide; for every batch of 5 slides, stain 1 with H&E, 1 with PAS and keep 3 unstained slides for possible future use
● Can detect immune complexes with antibodies or using fluorescence microscopy of H&E stained sections, fixed in Hollandeís fixative (Mod Pathol 2002;15:988)

Immunofixation
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● Best performed on unfixed, frozen sections
● Examine for IgG, IgM, IgA, C3, C1q, C4, fibrin, kappa and lambda
● Should include positive and negative controls for each run
● Immunoperoxidase may be a substitute (cheaper, can correlate with H&E, doesnít fade), but complement antigens are difficult to detect, may have higher background staining

Minimum glomeruli:
● 5-10 in general
● 10 for crescentic disorders
● 1 may be sufficient for diffuse lesions such as membranous glomerulonephritis

Immunohistochemistry: IgG, IgA, IgM, C1q, C3, C4, fibrinogen and fibrin
Frozen section: requested to determine adequacy (% sclerotic glomeruli) in donor kidney for transplant
Transplant biopsies: performed to assess rejection

Images and diagrams
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A: renal cortex with round red glomeruli; b: renal medulla without glomeruli


Diagram about dividing up core tissue if no dissecting microscope is present

Electron microscopy description
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● Uses osmium tetroxide or glutaraldehyde for fixation (cannot perform if tissue exposed to B5, Zenkerís or other mercury-based fixatives, can reprocess tissue from paraffin block)
● Embed in epoxy resin, stain semi-thin (one micron thick) sections with toluidine blue or methylene blue
● Obtain thin sections for EM, stained with uranyl acetate and lead citrate

End of Kidney non-tumor > Primary glomerular diseases > Biopsy-general

Ref Updated: 4/9/12


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