For best viewing please use the most current version of Internet Explorer or FireFox.
2015 Annual Meeting
Evening Specialty Conference - Renal Pathology
Sunday, March 22, 2015 - 7:30pm to 9:30pm
CC 304
Clinical histories are printed below. For the fastest viewing of virtual slides, click:

under each thumbnail image below. You must have Aperio ImageScope installed on your PC.
If you do not already have Aperio ImageScope, Windows users with administrator privileges may download and install a free version in order to view USCAP eAcademy Virtual Slides. Click the icon on the right to get your free copy:  
Or, click on slide thumbnail images to view each slide
in a Web-based slide viewer, which is somewhat slower.
Case title: A Diabetic Patient with Proteinuria
Clinical Summary:

Nephropathology Specialty Conference
Renal Biopsy Case 1:

Charles Alpers

Clinical History

A 58 year-old female with a 4-year history of type 2 diabetes mellitus controlled by diet and without previous evidence of end organ damage, first presented to a nephrologist with proteinuria of 4 g/24 hr associated with 1+ pitting edema. She had been followed by a primary care internist and was also being treated for mild hypertension. Physical exam was otherwise unrevealing. Urinalysis revealed a bland sediment. Additional laboratory testing revealed a serum creatinine of 1.9 mg/dl and normal serum and urine protein electrophoreses. Additional serologic studies were negative.  Serum electrolytes were unremarkable. The patient declined a renal biopsy and was treated with lisinopril, a statin and diuretics.
 
Three years later she was noted to have a slight rise in serum creatinine to 2 mg/dL, but now had 10 g/24 hr of proteinuria, normochromic normocytic anemia (Hct of 27%) without leukopenia, thrombocytopenia, or other hematological abnormalities. The patient was now amenable to undergoing renal biopsy.

Native kidney biopsy. PAS stain
Native kidney biopsy. PAS stain
Native biopsy
Native biopsy
Native biopsy Jones
Native biopsy Jones
Native biopsy Jones stain
Native biopsy Jones stain
Native kidney biopsy
Native kidney biopsy
Electron micrograph. Native kidney biopsy
Electron micrograph. Native kidney biopsy
Electron micrograph. Native kidney biopsy
Electron micrograph. Native kidney biopsy
Electron micrograph. Native kidney biopsy
Electron micrograph. Native kidney biopsy
Electron micrograph. Native kidney biopsy
Electron micrograph. Native kidney biopsy
Case title: A mother and son with CKD
Clinical Summary:

Patient A is a 43 year old woman from Eastern Europe who works as a part-time cleaner in the UK. The patient's general practitioner made a diagnosis of hypertension and chronic kidney disease and referred her for a nephrological opinion. She had three previous contacts with hospital services - an appendicectomy age 21, and ovarian "infection" aged 27 and an uncomplicated vaginal delivery of a son age 29. Elevated blood pressure was noted during a routine examination. She denied any history of urine infections of of non-steroidal inflammatory use. There is a family history of kidney disease - her father was on dialysis and died in his early sixties and her uncle died aged 49 with kidney disease.  Her medication included amlodipine 5mg daily. She had no allergies and lived with her husband and sn both of whom were well. Physical examination was unremarkable with no oedema. Blood pressure was 139/95. Urinalysis was bland. Following blood tests a renal biopsy was performed

Patient B was patient A's son who presented a year after patient A at age 17. His was referred because he had been found to have a creatinine of 1.7 mg/dL. He had no past medical history other than a chest infection at the age of 3. He denied urinary tract symptoms or infections. Physical examination was unremarkable. His blood pressure was 139/77. Following blood tests a renal biopsy was performed.

Patient A EM1
Patient A EM1
Patient A EM2
Patient A EM2
Patient A EM3
Patient A EM3
Patient B EM1
Patient B EM1
Patient B EM2
Patient B EM2
Patient B EM3
Patient B EM3
Patient B EM4
Patient B EM4
Case title: Hepatitis C virus positive patient with nephrotic syndrome
Clinical Summary:

Clinical history available before the biopsy

(for additional follow-up information see Case Discussion):

 

The patient is a 48-year-old Caucasian female. She weighs 147 pounds and is 5 feet 5 inches tall (BMI 24). She has a history of depression, anxiety, well controlled mild hypertension and hepatitis C virus infection diagnosed eight years ago. She is HIV and hepatitis B virus negative. She was started on peginterferon alpha nine months ago; she received 100 mg subcutaneously every week. Now, her hepatitis C viral load is undetectable. Approximately three weeks before the kidney biopsy, the patient realized lower extremity and facial swelling. She was found to have nephrotic syndrome with 9 g/24 h proteinuria and a serum albumin of 1.7 g/dL. Her serum creatinine rose up to 1.3 mg/dL from a baseline of 0.9 mg/dL. Urinalysis showed 5-10 RBCs/HPF. She had evidence of pancytopenia with WBC count of 1900 to 2700/µL, platelet count of 59,000 to 107,000/µL, hematocrit of 27, and hemoglobin of 9.1 g/dL. ANA negative, C3 low at 40 mg/dL; C4 low at 4 mg/dL. Serum and urine electrophoresis were negative for monoclonal spike. A CT of the pelvis and abdomen revealed mildly enlarged iliac and inguinal lymph nodes and borderline enlargement of the pulmonary hilar lymph nodes. She had scattered calcified lung nodules bilaterally in the bases. Her medications at presentation (in addition to peginterferon alpha) included furosemide, losartan, aspirin, Percocet, and clonazepam.  A renal biopsy was performed.











Case title: Acute Kidney Injury in a Diabetic Woman
Clinical Summary:

A 67 year-old woman presented to an outside hospital with malaise, diarrhea and bilateral lower extremity edema for the past 10 days. A SCr of 4.1 was noted 4 days previously. In the ER she was found to have BUN/SCr=60/3.8.

She has had Hypertension for a long time, (treated with an ARB) and Type 2 Diabetes mellitus (Insulin) for the past 12 years, complicated by Diabetic neuropathy and possible retinopathy. One year ago she presented with Diabetic Ketoacidosis and Acute Kidney Injury (SCr peaked in the 3’s but returned to her baseline of 0.8). A renal ultrasound, performed several months ago, was normal.

The patient has spinal stenosis, is s/p steroid injections, and began taking Naproxen, 500 mg BID several weeks prior to admission. She also has a history of hypothyroidism (Synthroid) and COPD.

She is poorly compliant with her medications.

Masson Trichrome; Original Magnification 10X.
Masson Trichrome; Original Magnification 10X.
Masson Trichrome; Original Magnification 10X.
Masson Trichrome; Original Magnification 10X.
Masson Trichrome; Original Magnification 10X.
Masson Trichrome; Original Magnification 10X.
PAS (left), Toluidine Blue 1-micron plastic section; Original Magnification 40X.
PAS (left), Toluidine Blue 1-micron plastic section; Original Magnification 40X.
PAS; Original Magnification 20X.
PAS; Original Magnification 20X.
PAS; Original Magnification 40X.
PAS; Original Magnification 40X.
H&E (left), PAS; Original Magnification 40X.
H&E (left), PAS; Original Magnification 40X.
Direct immunofluorescence for Albumin; Original Magnification 40X.
Direct immunofluorescence for Albumin; Original Magnification 40X.
Transmission Electron Microscopy; Original Magnification 3000X.
Transmission Electron Microscopy; Original Magnification 3000X.
Transmission Electron Microscopy; Original Magnification 4000X.
Transmission Electron Microscopy; Original Magnification 4000X.
Transmission Electron Microscopy; Original Magnification 15,000X.
Transmission Electron Microscopy; Original Magnification 15,000X.
Case title: A rare cause of nephrotic range proteinuria.
Clinical Summary:

A 14 year-old white girl was referred to the pediatric nephrology clinic for management of new onset hypertension, associated with nephrotic range proteinuria, microscopic hematuria, and normal kidney function.  Her past medical history was notable for neurological abnormalities during infancy, which led to the discovery of methionine synthase deficiency (Cbl G disorder). Her medical course had been complicated by seizures, cortical blindness, developmental delay and intellectual disability. She had no prior history of kidney disease and no family history of kidney disease.  Medications consisted of vitamin B12 injections and oral betaine, folinic acid and vitamin B6. Physical exam revealed blood pressure 130/89 (90th percentile for age/height = 117/75); BMI = 22 kg/m2; no rash; and no edema.