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Index

Histologic patterns of glomerular


changes

When evaluating a renal biopsy we must follow a systematic process


that prevents us missing a lesion in any of the four histologic
compartments: glomeruli, interstitium, tubules or vessels. To decide the
primary site of the injury is not an easy task: injuries in a part of nephron
affect the other compartments. We can have a vascular injury that when
advancing the process will finish affecting glomeruli, interstitium, and
tubules; or the injury can begin in glomeruli, which will affect the
remaining histologic structures. Each compartment displays more or less
characteristic histopathologic features that guide the pathologist in the
task of determining the primary site of injury.
Most of morphologic patterns of renal injury do not correspond with only
one disease. In addition to the morphologic features we need clinical
data, immunofluorescence, and, in many cases, electron microscopy to
adequately classify the renal alterations.
Patterns of glomerular lesions
Glomerular changes can be focal (only in some glomeruli) or diffuse (in
all or almost all the glomeruli), and segmental (only a part of the
glomerulus) or global (the entire glomerulus). The first step in the
evaluation of the glomerular alterations is to determine the extension of
the affectation.
The glomeruli can display global sclerosis; when this happens can be
impossible to determine the cause of the damage. Ischemia originated
glomerular sclerosis have a characteristic pattern of retraction and
collapse of capillary tuft (PAS-positive) surrounded by fibrotic tissue
(PAS-negative) (Figure 1). Sometimes can be demonstrated rests of a
crescent, or remaining fragments of tuft fibrinoid necrosis, or immune
deposits in not completely sclerosed tufts, which can orient to a
glomerulonephritis as cause of the glomerular sclerosis.
Figure 1. Globally sclerosed glomerulus with ischemic origin of the injury. Remaining
material of the capillary tuft is seen more intensively stained with PAS (left) and
methenamine-silver stains (right) because sclerosed glomeruli contain abundant type IV
collagen. The fibrous tissue that surrounds the sclerosed capillary tuft proliferates from the
capsule and is negative, or weakly positive, with PAS and silver stains because contains a
different collagen, predominantly type I. (PAS, and methenamine-silver, X300).
The focal and segmental glomerulosclerosis is a relatively frequent
lesion produced by multiple causes. Only when there are clinical findings
of glomerulopathy and other glomerulonephritis are ruled out, it can be
diagnosed as a specific disease: focal and segmental
glomeruloesclerosis. This glomerular lesion can be, or no,
accompanied by hyaline deposits (Figure 2); the importance of this type
of deposits, respect to the pathogenesis, is uncertain (see the chapter of
focal and segmental glomeruloesclerosis). When this injury is not
associated to clinical expression of glomerulopathy or it is assumed that
it is secondary to other renal or systemic alterations, perhaps we would
lomerular scar.
call it with other name like g
Figure 2. Glomerulus with segmental sclerosis (left superior corner). There are segments
with preserved architecture. Notice small hyaline segments (positive with the PAS stain,
arrow); they are proteins and other components. (PAS, X400).
In the spectrum of focal and segmental glomeruloesclerosis there are
several morphologic aspects that will be seen in the respective chapter,
but two are very characteristic: tip lesion and collapsing lesion. The
first is defined by the presence of at least one segmental lesion involving
the tip domain with either adhesion between the tuft and Bowmans
capsule at the tubular lumen or neck, or confluence of podocytes with
parietal or tubular epithelial cells, at the tubular lumen or neck, it can be
seen simply like an adhesion of the capillary walls to the Bowmans
capsule at the origin of proximal tubule or like a hyaline segment with
podocyte hypertrophy and/or foam cells (Figure 3). Collapsing lesion is
characterized by tuft collapse, global or segmental, accompanied of
noticeable hypertrophy and hyperplasia of podocytes (Figure 4).
Figure 3. Adhesion and sclerosis at the tip domain of the tuft, in other words, at the tubular
lumen or neck in the Bowmans capsule (arrows) (although the origin of tubule is not
perfectly identified here). This lesion has been associated with a less aggressive course in
some works, but we do not found this good prognosis in our Hispanic patients. (Massons
trichrome, X400).
Figure 4. Almost global collapse of glomerular tuft. Notice the loss of capillary lumens and
notorious proliferation of visceral epithelial cells (podocytes). Sometimes the proliferation is
so intense that it can fill the Bowmans space and be confused with an epithelial crescent.
The collapsing lesion can be global or segmental. (methenamine-silver, X400).
Endocapillary proliferative glomerulonephritis
It is an increase of the number of tuft cells occluding the glomerular
capillaries and usually accompanied by mesangial hypercellularity. The
proliferating cells are endothelial, mesangial, and inflammatory cells
infiltrating the tuft (leukocytes). The nature of cells contributing to
glomerular hypercellularity is important pathogenetically, but the
intraglomerular location of the cells is more important in terms of the
diagnosis of GN. Glomeruli appear large, with expanded tuft, capillary
lumens difficult to see or they are small, and there are noticeable
increase of cells that have nuclei with variable size and form (Figures 5
and 6). When the inflammation is severe we can see tuft necrosis or
karyorrhexis (nuclei fragmentation), fibrin (amorphous material that
appear eosinophilic with H&E stain or red, due to the fuchsin, with the
trichrome stain) and destruction of capillary walls (better demonstrated
with silver stain) (Figure 7).

Figure 5. Global cellular proliferation with increase of the glomerular size; there is loss of
capillary lumens and nuclei with variable aspect in form and size, suggesting that there are
several proliferating cell types. In some cases the mesangial proliferation contributes to
accentuate the lobules of the glomeruli: lobulation. (H&E, X400).

Figure 6. Severe cellular proliferation that obstructs the capillary lumen (endocapillary).
Abundant polymorphonuclear leukocytes in the tuft: exudative form. This aspect suggests
post-infectious GN. (H&E, X600).
Figure 7. Endocapillary proliferative GN with a segment of necrosis (among the arrows) that
is eosinophilic (pink); it is accompanied by nucleus fragments (karyorrhexis) and
polymorphous. In these lesions there is capillary wall rupture and they are frequently
associated to crescents (H&E, X600).
Endocapillary hypercellularity is a true glomerulonephritis (GN) and
when it is diffuse usually it is due to post-infectious GN, lupus nephritis,
or membranoproliferative GN. Focal proliferativa GN (usually segmental)
is, more frequently, due to lupus nephritis, IgA nephropathy, vasculitis,
bacterial endocarditis, or other chronic infections.
If there are many polymorphonuclear leukocytes in the tuft, the lesion is
known as exudative GN and it is suggestive of postinfectious GN or
membranoproliferative GN (Figure 6).
Extracapillary proliferative glomerulonephritis (crescentic)
It is characterized by increased cellularity in the Bowmans space due to
proliferation of the parietal epithelium or infiltration of inflammatory cells.
This lesion is termed crescent. By definition, it should be al least two cell
layers thick and cover a third of the glomerular circumference (Figures 8,
9 and 10). It must be differentiated of podocyte proliferation that
sometimes can produce a crescentic aspect. Crescents can be
accompanied, or no, by endocapillary proliferation. Frequently crescents
are associated to necrosis of the tuft and/or rupture of the capillary walls.
When there is destruction of the Bowmans capsule periglomerular
granulomas can develop, but it do not indicate a granulomatous disease
(Figure 10). Crescentic GN is diagnosed when more than 50% of the
glomeruli are affected by extracapillary proliferation.

Figure 8. Extracapillary proliferation. Notice the collapsed tuft in the center of the
microphotography. There is a clear space between tuft and the crescent. The green arrows
point the Bowmans capsule and the blue arrows point the internal edge of the crescent. This
proliferation is formed by epithelial cells and mononuclear inflammatory cells. (H&E, X400).
Figure 9. Compressed tuft, in the center of the glomerulus, by a dense circumferential
cellular proliferation that occupies the entire Bowmans space. The arrows indicate rupture of
capillary walls, a frequently associated phenomenon to the crescent. (Methenamine-silver,
X300).
Figure 10. In this case the crescent has evolved with collagen proliferation, which is
demonstrated by the fibres stained with silver stain: green arrows (they are also easily
demonstrated with trichrome stain). The lesions in this stage are called fibroepithelial
crescents. When the entire crescent has been replaced by fibrous tissue and it has not
epithelial cells, is called fibrous crescent and it is a chronic, irreversible lesion. In the
microphotography also there is a zone with Bowmans capsule destruction: red arrow.
(Methenamine-silver, X300).
Crescentic proliferation can be seen in anyone of the endocapillary
proliferative GN or it can be found as pure extracapillary proliferation. In
this last case usually is associated to (or due to) a small vessels
vasculitis (Wegeners granulomatosis, microscopic polyangiitis, or
Churg-Strauss disease), or can be an idiopathic crescentic GN.
Crescentic GN can be also seen in anti-glomerular basement membrane
disease.
As seen, the term crescentic glomerulonephritis (crescents in more than
50% of glomeruli) is not a specific diagnosis, but, a manifestation of
glomerular damage due to many causes.
Mesangial cellular proliferation
Mesangial hypercellularity has an ample rank, from slightest, difficult to
demonstrate without histomorphometric analysis (by computer) until
most severe forms with glomerular distortion or marked lobulation of the
tuft (Figures 11 and 12). In many cases hypercellularity is accompanied
by increase in the extracellular mesangial matrix (Figure 13). Mesangial
proliferation can be produced by several mechanisms and can be an
unspecific response to many glomerular insults. In many cases immune
deposits in the mesangium are demonstrated. This pattern of injury can
be seen in lupus nephritis (class II), IgA nephropathy, minimal change
disease (and its possibly related: IgM nephropathy), focal and segmental
glomerulosclerosis, some cases of membranous GN, in the rare
diseases C1q nephropathy and mesangial GN with C3 deposits,
resolving postinfectious GN, and others.
Figure 11. In this glomerulus we can see cellular proliferation in diverse mesangial areas.
We consider proliferation when there are more than 3 nuclei in a mesangial area. The
arrows point areas with increase of cellularity, in this case: mild proliferation. (H&E, X.400).

Figure 12. . Just as in the previous photo, we can see, in this image, cellular proliferation
limited to the mesangium, with well preserved peripheral capillary walls and without
obstruction of its lumens, although these appear diminished. Unlike to the previous one, in
this photo we see a severe increase of the cellularity, which give a lobulated aspect to the
tuft. See the relative homogeneity of nuclei and compare with the endocapillary proliferation
in Figures 5 and 6. (H&E, X400).

Figure 13. With stains that highlight the mesangial matrix (silver and PAS) is notorious the
increase of the extracellular components of the mesangium that usually accompany
mesangial hypercellularity. Pure increase of the matrix (without cellular increase) can be
seen in some types of glomerular injury. (PAS, X400).
Mesangial matrix increase without hypercellularity
Expansion of the mesangial matrix (production of components of the
mesangial extracellular matrix) is a response to many injuries against
glomeruli. Mesangial matrix expansion is also evidenced when there are
pathologic deposits of proteins or circulating substances:
fibrillary/immunotactoid glomerulopathy, amyloidosis, light and heavy
chain deposition disease, and diabetes mellitus.
When there is disruption of the mesangial matrix with capillary lumen
expansion (microaneurisms), the lesion is called: mesangiolysis, and it
is more frequently demonstrated in haemolytic-uremic syndrome,
diabetes and malignant hypertension (Morita T, et al. Mesangiolysis: an update.
Am J Kidney Dis. 1998;31:559-73 [PubMed link]).
Glomerular basement membrane (GBM) alterations
GBM can be altered by immune or nonimmune mechanisms. The
membranous transformation, seen in primary or secondary membranous
GN, is the reaction of the GBM to subepithelial deposits (between GBM
and the visceral epithelial cell). These deposits generate
basement-membrane-like material production that tries to surround them
leading to formation of perpendicular projections (or cuplike
projections) that are seen as spikes (Figure 14).

Figure 14. GBM reaction to the subepithelial deposits is seen as perpendicular projections
to the GBM in its external part: spikes, demonstrated here with silver stain (arrows). The
immune deposits (no visible here) are between spikes. (Silver, X1000).
Subendothelial deposits induce circumferential extension of the
mesangium into the glomerular capillary walls (mesangial interposition; it
can include mesangial cells) that generates synthesis of GBM-like
material. This neoformed material is located between the endothelial cell
and the deposit or the interposed mesangial cell. Thus, a double contour
of the basal membrane is formed, being the internal contour the
neosynthesized one (Figures 15 and 16).
Figure 15. This case corresponds to type I membranoproliferative GN. There is cellular
proliferation and images in double contour (sometimes termed: tram-tracking, splitting, or
duplication of the GBM) (arrows). (Methenamine-silver, X400).

Figure 16. Many and extensive subendothelial deposits. The immune deposits are positive
with the fuchsin used in trichrome stain. The double contour forms due to synthesis of
basement-membrane-like material between the endothelial cells and the deposits. (Massons
trichrome, X400).
Double contours are classically found in type I and III
membranoproliferative GN, but it can be also seen in lupus nephritis,
cryoglobulinemia and some diseases in which subendothelial immune
deposits are not demonstrated: thrombotic microangiopathy and chronic
transplant glomerulopathy (Figure 17).

Figure 17. Glomerulus from a kidney allograft with chronic transplant glomerulopathy. The
double contours found in this alteration (arrows) are not caused by subendothelial immune
deposits. Cellular proliferation is not seen in these cases. (Methenamine-silver, X400).
In the GBM is also possible find organized deposits as in amyloidosis
(Figure 18) and fibrillary/immunotactoid glomerulopathy.
Figure 18. Acellular deposits in interstitium. Congo-red demonstrate positivity for amyloid.
On the left we see the reddish colour that gives the staining, but the true positivity is marked
by apple green birefringence when polarized lenses are used (right). (Congo-red stain,
X200; on the left with normal lenses; on the right with polarized lenses).
Diffuse thinning of the GBM: thin basement membrane disease.
Irregularity and multilayering or splitting of the GBM: Alports
syndrome.
At present, these two diseases tend to be grouped with the name type IV
collagen nephropathy.
Diffuse thickening of the GBM: diabetes mellitus, hypertension.
Ischemic changes in glomeruli can be demonstrated by retraction,
wrinkling, and folding of the capillary walls; similar changes can be also
observed in basement membranes of the tubules.
Immunopathologic patterns
In addition to immunoglobulins (Igs) and/or complement components
deposited in a disease, the pattern of deposition is also important. Linear
deposition in the capillary walls is observed in anti-GBM disease (mainly
IgG) (Figure 19a), and unspecifically IgG in diabetes mellitus (Figure
19b). Granular parietal deposition of several Igs and complement is seen
in membranoproliferative GN (subendothelials) (Figure 20a), in
post-infectious GN (subepithelials) (Figure 20b), in membranous GN
(subepithelial and intramembranous) (Figure 20c).
Figure 19a. Linear Positivity for IgG demonstrated by immunofluorescence. The capillary
walls are seen well demarcated by a continuous, well-defined line. This pattern is observed
in anti-GBM disease and in diabetes mellitus (IgG and albumin), being in this last case an
unspecific immunostaining. In this image we see a crescent compressing the glomerular tuft
(Immunofluorescence for IgG, anti-human-IgG antibodies marked with fluorescein,
fluorescence microscopy, X400).
Figure 19b. Linear Positivity for IgG in diabetes mellitus: "pseudolinear"
(Immunofluorescence for IgG, anti-human-IgG antibodies marked with fluorescein,
fluorescence microscopy, X400).
Figure 20a. Granular subendothelial deposits. This pattern is seen in some glomerular
diseases with immune complexes deposits. The photo corresponds to a case of lupus
nephritis (Immunofluorescence for C3, anti-humn-C3 antibodies marked with fluorescein,
fluorescence microscopy, X400).

Figure 20b. Granular positivity for C3 in a case of post-infectious GN. This pattern
isdescribed as "bumps and humps" or "lumpy-dumpy", traditionally associated with
postinfectious GN (Immunofluorescence for C3, anti-humn-C3 antibodies marked with
fluorescein, fluorescence microscopy, X400).
Figure 20c. Granular positivity for IgG demonstrated by immunofluorescence. There are
many grains of diverse size in the capillary walls (parietals). In some capilaries a "reticular"
appearence can be seen. The photo corresponds to a case of membranous GN, with the
more typical appearence of subepithelial deposits (Immunofluorescence for IgG,
anti-humn-IgG antibodies marked with fluorescein, fluorescence microscopy, X400).

Mesangial deposits are granular and they can be found in IgA, IgM, and
C1q nephropathies, in C3 mesangial GN, lupus nephritis class II,
resolving postinfectious GN, and others.
Figure 21. IgA Positivity in mesangial areas in a case of IgA nephropathy. See that capillary
walls are not marked by the immunostaining. Only there is a positivity that draws irregular
areas that correspond to the mesangium. (Immunofluorescence for IgA, anti-human-IgA
antibodies marked with fluorescein, fluorescence microscopy, X400).
Combinations of immunopathologic patterns can be found in several
diseases with immune complexes deposition like lupus.
Negativity for immune deposits is also an important feature in renal
pathology; this fact is evidenced in diseases as minimal change disease
and crescenti pauciimmune GN that, by definition, does not have
deposition of Igs or complement (or if there is deposition this is weak).
The immunoglobulin type, the complement fraction, or the light chain
deposited are also important in the differential diagnosis.
Figure 22. Tubulointerstitial positivity for Igs or complement can be see in some
autoimmune disease, mainly lupus, and exceptionally in other diseases.
(Immunofluorescence for IgG, anti-human-IgG antibodies marked with fluorescein,
fluorescence microscopy, X400).
Electron microscopy
Ultrastructure helps to determine very important features in the definition
of glomerular diseases and its differential diagnosis.
The location of electron-dense deposits (generally immune) with respect
to the GBM: subepithelials, subendothelials, intramembranous or
mesangials (Figures 23 to 25).
Figure 23. Electron-dense subepithelial deposits in membranous GN (arrows). Notice also
the projections of basement membrane-like material surrounding deposits. EM, original
magnification, X6.000.
Figur3 24. Subendothelial deposits in membranoproliferative GN (red arrows). Notice also a
capillary segment with double contour. EM original magnification, X6.000.
Figure 25. Mesangial electron-dense deposits in a case of IgA nephropathy (arrows). EM,
original magnification, X6.000.
[Subepithelial deposits in membranous GN (link)] [Another image with
subepithelial and intramembranous deposit (link)]
One important issue in ultrastructural assessment is the aspect of
podocytes and foot process. A frequent alteration is foot process
effacement or fusion; this feature can be found in any disease causing
nephrotic syndrome, but it is a characteristic feature in minimal change
disease (Figure 26).
Figura 26. Complete loss of podocyte processes (effacement or "fusion"). The blue arrow
indicates an area of detachment (loss) of the podocyte. EM, original magnification, X8.000.
[Foot processes effacement or fusion (link)] [Another image in MCD
(link)]
The characteristics of the GBM: diffuse thinning (thin basement
membrane disease) (Figure 27), irregularities, multilayering and
fragmentation (Alports disease) (Figure 28), and diffuse thickening
(diabetes mellitus) (figure 29) are key diagnosis features in
ultrastructural pathology.
Figura 27. Diffuse thinning of glomerular basement membranes. The homogeneous thin
appearance suggests the alteration, however, it is necessary to measure its thickness and,
of course, correlate with clinical features: this finding does not necessarily mean "disease".
EM, original magnification, X4.000.

Figura 28. Glomerular basement membrane very irregular, with areas of thinning and other
very thickened in a case of Alport disease. EM, original magnification, X10.000.
Figura 29. Diffuse thickening of the glomerular basement membrane (note the result of
measuring its thickness) in a case of diabetes mellitus; This change, though unspecific, can
help in the early diagnosis of diabetic nephropathy. ME, original magnification, X10.000.
Myelin figures in Anderson-Fabrys disease, microfibrils in
fibrillary/immunotactoid glomerulopathy, and other almost specific
features are very important and constitute another reason for
ultrastructural study in kidney pathology.
See the section: Electron microscopy in renal biopsies.
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