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Teresita Tuazon
Pathology of Glomerular Diseases Exam # 1
OUTLINE
I. Review of the Glomerulus
II. Histologic Alterations
III. Pathogenesis of Glomerular Injury
IV. The Glomerular Diseases
a. Nephrotic Syndrome
b. Minimal Change Disease
V. Focal Segmental Glomerulosclerosis
(FSGS)
VI. Membranous Glomerulonephropathy
VII. Nephritic Syndrome
VIII. Acute Glomerulonephritis
IX. Glomerulonephropathies Associated
with Isolated “Essential” Hematuria
a. IgA Nephropathy ( Berger’s Disease
)
b. Thin Basement Membrane Disease
c. Alport’s Disease Figure 3. low power EM of renal glomerulus; CL – capillary
d. Non-specific changes lumen; MES – mesangium; END – endothelium; US –
urinary space
X. Membranoproliferative
Glomerulonephritis
XI. Acute Renal Failure
Review of the Glomerulus
Figure 1. The normal glomerulus Figure 5. glomerular BM and blood space interface.
Podocytes are seen oriented toward the epithelial cell.
Glomerular BM negatively charged thus anionic molecules
are repelled.
Normal Glomerulus
• Consists of an anastomosing network of
capillaries lined by fenestrated endothelium
invested by two layers of epithelium
• The anatomical glomerulus is enclosed by two
layers of epithelium, Bowman's capsule.
• Cells of the outer or parietal layer of Bowman's
capsule form a simple squamous epithelium.
• Cells of the inner layer, podocytes in the
visceral layer, are extremely complex in shape.
Figure 2. glomerulus (normal) • Between the podocytes and the endothelial cells
of the capillaries we find a comparatively thick
basal membrane.
• Mesangial cells in the glomerulus form the
connective tissue that gives structural support to
4. CELL-MEDIATED IMMUNITY
• Sensitized T cells can cause glomerular
injury
• Presence of macrophages and T
lymphocytes in glomeruli, particularly in
allografts
Figure 10. Complement activation • May account for no deposits in GN or non-
2. GLOMERULAR LOCALIZATION OF IMMUNE correlation of deposits with severity of
COMPLEXES damage
• Molecular charge and size From Block B Trans:
• Highly CATIONIC – cross GBM – a. Neutrophils and monocytes release
(1) subepithelial protease (GBM degradation), free
radicals (cell damage), and arachidonic
• Highly ANIONIC – repelled - (2) subendothelial
acid metabolites (decrease in GFR)
• More NEUTRAL charge – (4) mesangial b. Macrophages, T-lymphocytes and
• Large complexes are cleared by the natural killer cells when activated
reticuloendothelial system release a vast number of biologically
active molecules.
c. Platelets release eiconasoids and
1 2 growth factors that contribute to the
manisfestation of glomerulonephritis.
d. Resident glomerular cells like
4 mesangial cells can be stimulated to
produce cytokines, chemokines and
growth factors
5. CELL-MEDIATED MECHANISMS
3 • Minimal change disease, crescenteric GN type
III, allograft rejection, acute drug-induced
interstitial nephritis, various vasculitides
o Endogenous antigens
o Exogenous antigens
• Anti-TBM disease in Brown-Norway rats, acute
tubulointerstitial nephritis in mice, acute
glomerulitis in bursectomized chicken
Figure 11. Localization of immune complexes in the
glomerulus
3. EPITHELIAL DETACHMENT
• Results when an antibody cytokine toxin destroys
the BM leaving no more surface for the cells to
attach
• Effacement of foot processes, vacuolization,
retraction and detachment of cells from the GBM.
Light Microscopy
• Some glomeruli (especially juxtamedullary ones)
with segmental sclerosis (mesangial matrix
material, collapse, basement membrane- like
material , +/- hyalinosis
• In immunofluorescence microscopy:
o Negative immunofluorescence staining
within glomeruli – no immune
complexes
Pathogenesis
• initiating pathogenetic mechanisms are varied
• common element is injury manifested by
sclerosis in the setting of nephrotic range
proteinuria.,
• Degeneration and focal disruption of visceral
epithelial cells
• Hyalinosis and sclerosis represent entrapment
of plasma proteins in extremely hyperpermeable
foci with increased ECM deposition
• Mutations in genes encoding for the proteins
nephrin and/or podocin causes increased
permeability to proteins – PROTEINURIA!
Figure 21. Tubular atrophy – normal glomerulus but with
thickened tubular walls, it could indicate presence of Primary/idiopathic FSGS
FSGS even if glomerulus is normal as seen here.
Secondary/variants FSGS
Immunofluorescence Microscopy • I.V. drugs
• Usually normal except for sclerotic segment • Collapsing gn: HIV, parvovirus B-19,
which may have IgM, with or without C3 pamidronate, CS2, Loa Loa
• Obesity-associated - reversible with weight
reduction
• Familial FSGS - podocin, alpha-actinin-4
mutations
• Congenital - Finnish type (nephrin mutation)
• Cholesterol emboli
• Lithium
• Mitochondrial myopathies/cytopathies
Observations:
Membranous Glomerulonephropathy
Clinical Features
• Proteinuria with or without the full nephrotic
syndrome - most common finding
• Peak incidence in the fourth to fifth decades
• Male preponderance
• Most common cause of nephrotic syndrome in
adults (remember minimal change disease –
most common cause of NS in children!)
Clinical Course
• Spontaneous remission of proteinuria occur in
approximately ¼ of patients, approximately half Figure 27. LM: silver staining BM spikes trying to cover
will have stable renal function with or without the deposits
continued proteinuria
• Minority of patients will have slow decline in renal
function, a few will have rapid decline in renal
function
• 1/3 progress, 1/3 remit, 1/3 protenuria only
In light microscopy:
• Normal to extreme diffuse thickening of the
capillary wall
• +/- tuft hypercellularity
• foam cells in interstitium
In electron microscopy:
• Numerous subepithelial deposits (+/-) spikes of
GBM in between
In immunofluorescence microscopy:
• Finely granular diffuse capillary wall staining (-) Figure 28. IF: Finely granular diffuse capillary wall
IgG, (+/-) C3 and other immunoreactants
Nephritic Syndrome
• Hematuria
• Proteinuria
• Decreased glomerular filtration rate
• Elevated BUN and serum creatinine Figure 31. IF: Variable-sized coarse granular deposits of
• Oliguria immunoglobulins and complement in glomerular loops.
• Salt and water retention
• Edema
Electron Microscopy
• Hypertension
• “Immune-type” deposits on subepithelial
Glomerular Changes surface described as “humps”
• Leucocytic infiltration • Occasional patchy GBM thickening
• Hyperplasia of glomerular cells
• Necrosis (severe lesions)
• Injury to capillaries
Acute Glomerulonephritis
Clinical Features
• Also called poststreptococcal or postinfectious
glomerulonephritis
• Latent period between infection and onset of GN
( 1-2 wks for pharyngitis and 3-6 wks for skin
infections )
• Smoky urine and edema common initial manif,
hypertension common, transient oliguria
Light microscopy
• Global and usually uniform hypercellularity
• Capillary lumina may be occluded Figure 32. EM: Variable-sized granular dense deposits of
• Neutrophils frequent in the acute phase IgG and C3 (“humps”) irregularly arrayed in the
( exudative glomerulonephritis) subepithelial space of the glomeruli.
Pathogenesis
Immunofluorescence Microscopy
• Mesangial granular IgA (in the absence of SLE,
Figure 33. Hypercellular glmeruli due to proliferation of HSP, active liver disease)
endothelial cells and mesangial cells, swelling of • Usually C1q is absent
endothelial cells, and inflammatory infiltrate (neutrophils
and monocytes). Initially, tubules are not affected (but as
disease progresses, they may present hydropic change).
IgA Nephropathy
Clinical Features
• Most common during the 2nd and 3rd decades Figure 36. IF: Granular deposits of IgA and C3 in the
• Male preponderance glomerular mesangium. The fundamental characteristic in
• Asymptomatic microhematuria to rapidly IgA Nephropathy is the intense, diffuse mesangial
progressive renal failure immunostaining for IgA that is limited to mesangial areas,
• 5 to 15% have nephrotic syndrome (without deposits in capillary walls). Diagnosis rests on the
finding of dominant IgA mesangial deposits. C3 is also
Light Microscopy Histologic Subclasses present in mesangial areas, but usually equal to or less
• Type I – Minimal histologic lesion than IgA staining.
• Type II- Focal segmental glomerulosclerosis-like Electron Microscopy & Clinical Course
• Type III – Focal proliferative glomerulonephritis • Mesangial electron dense deposits
• Type IV – Diffuse proliferative GN • Variable clinical course and prognosis
• Type V – Advanced chronic GN
Figure 37.
Pathogenesis
March 3, 2009 | Tuesday Page 9 of 16
Canoy, Carasco, Cielo,
Co
OS 214 Renal Dr. Teresita Tuazon
Pathology of Glomerular Diseases Exam # 1
– presence of IgA immune complexes in the Unfortunately it usually destroys the transplant.
glomerular tufts
– Presumably mucosal derived IgA combines with
antigens to form circulating immune complexes Membranoproliferative Glomerulonephritis
that deposit in the glomerular mesangium.,
Clinical Features
• Nephrotic syndrome common
• May have manifestations of the acute nephritic
syndrome such as hematuria,
• ( gross or microscopic), hypertension
MPGN Type I
Light Microscopy
• Proliferative, polymorphonuclears
• Lobulation/ tram-tracking
Alport syndrome
• In Alport syndrome, type IV collagen, one of the
proteins that makes up the GBM, is absent or
abnormal. Although the GBM looks normal in
childhood, it deteriorates with time because it
lacks the special type IV collagen that should be
there
• Alport syndrome is much more common in boys
and men because the gene that usually causes it
(called COL4A5) is on the X chromosome.
Women have two X chromosomes (XX), so they
usually have a normal copy as well as an
abnormal copy of the gene
• in less than 1 in 20 Alport transplants) kidney
transplants meet with a unique problem. Figure 41. Increased mesangial matrix (stained black with
• Because the transplanted kidney has normal type silver stain)
IV collagen, the immune system may see it as
'foreign' and attack it. This causes Alport anti- Immunofluorescence Microscopy
GBM disease, which is very similar to the kidney • Broad capillary wall deposits –
disease seen in Goodpasture's disease. • C3 +/- other things
March 3, 2009 | Tuesday Page 10 of 16
Canoy, Carasco, Cielo,
Co
OS 214 Renal Dr. Teresita Tuazon
Pathology of Glomerular Diseases Exam # 1
Immunoflourescence Microscopy
• Broad capillary wall deposits – C3 +/-, other
things, extraglomerular deposits
Electron Microscopy
• Large electron dense deposits in GBM, +/-
TBM,BC,etc
Robbins book notes
Types I and II have altogether different ultrastructural and
immunofluorescent features.
Type I MPGN (two thirds of cases) is characterized by the
presence of subendothelial electron-dense deposits.
Mesangial and occasional subepithelial deposits may also be
present. By immunofluorescence, C3 is deposited in a granular
pattern, and IgG and early complement components (C1q and
C4) are often also present, suggesting an immune complex
pathogenesis.
Clinical Features
• Clinical onset of disease usually abrupt
• Severe oliguria or anuria common at initial
examination
• Course is aggressive if without treatment
Robbins book notes
Rapidly progressive glomerulonephritis (RPGN) is a syndrome
associated with severe glomerular injury and does not denote a
specific etiologic form of glomerulonephritis. It is characterized
clinically by rapid and progressive loss of renal function
associated with severe oliguria and (if untreated) death from
renal failure within weeks to months. Regardless of the cause,
the histologic picture is characterized by the presence of
crescents in most of the glomeruli (crescentic
glomerulonephritis). These are produced in part by proliferation
of the parietal epithelial cells and Bowman capsule and in part
by infiltration of monocytes and macrophages.
RPGN may be caused by a number of different diseases, some
restricted to the kidney and others systemic. Although no single
mechanism can explain all cases, there is little doubt that in
most cases the glomerular injury is immunologically mediated.
Thus, a practical classification divides RPGN into three groups
on the basis of immunologic findings. In each group, the
disease may be associated with a known disorder or it may be
idiopathic.
Light Microscopy
• Over 50% of glomeruli with crescents.
• Look at the most preserved glomeruli for tuft
hypercellularity
Figure 52.
Types of ANCA
1. C-ANCA - cytoplasmic pattern
• Major specificity: proteinase 3
• Major clinical association: Wegener’s
granulomatosis
2. P-ANCA - perinuclear pattern
• Major specificity: myeloperoxidase
• Major clinical associations: microscopic Figure 54. Cellular crescent formation*
polyangiitis and renal-limited crescentic
glomerulonephritis
Figure 57.
Figure 57.