However, other considerations would also include underlying infection (particularly mycobacterial or fungal), autoimmune disease, as well as sarcoidosis (diagnosis of exclusion).

The most common consideration to include in your differential for granulomatous tubulointerstitial nephritis is drug/hypersensitivity reaction.

The image of a Jones silver stain depicts a small vessel within the center of the image along with a surrounding, somewhat well-formed non-necrotizing granuloma with associated touton giant cell (approximately 4-5 o'clock).

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What considerations should be included in your differential diagnosis given the provided histologic finding?

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Here is today’s #eyeSCANdy! Dysmorphic red blood cells from the urine of a patient with crescentic glomerulonephritis.

Photo courtesy of Dr. Stephen Bonsib. #renal #pathology #kidneypath

A sample from the pathology teaching slide set on Membranous Nephropathy
Research Recommendation, jointly prepared by Arkana Laboratories and @goKDIGO. http://KDIGO.org/guidelines/gd/

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5/
Lei L, Oh G, Sutherland S, Abra G, Higgins J, Sibley R, et al. Myelin bodies in LMX1B-associated nephropathy: potential for misdiagnosis. Pediatric Nephrology. 2020;35(9):1647-57.

4/ References:
Woywodt A, Hellwg S, et al. A wild zebra chase. Nephrol Dial Transplant 2007;22(10):3074-7.

Bracamonte ER, Kowalewska J, et al. Iatrogenic phospholipidosis mimicking Fabry disease. Am J Kidney Dis 2006; 48:844-850.

3/ Correlation with other diagnostic tests such as alpha galactosidase activity and/or genetic analysis is required for the definitive diagnosis of Fabry's disease.

2/ This finding is most suspicious for Fabry disease. The differential diagnosis includes LMX1B mutation or iatrogenic phospholipidosis secondary to drugs such as chloroquine, amiodarone, antidepressants, and anti-cholesterol medications among others (see references below).

1/ This is a toluidine blue section showing numerous densely stained lipid inclusions in podocytes, some with concentric laminations.

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The degree of chronic injury should help inform the selection and aggressiveness of therapy and provide an objective measure of the likelihood of functional recovery.  

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Interestingly, such morphologic changes can either result from acute renal injury followed by weeks to months of ongoing damage or an insidious, decades-long kidney disease without an identifiable acute event. 

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This renal biopsy illustrates severe chronic kidney injury and its effects on all major compartments of the cortex: most glomeruli are globally sclerotic, the atrophic tubules are widely spaced, the interstitium is fibrotic, and the arterial walls show intimal fibrosis. 

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What’s your diagnosis?

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Here is today’s #eyeSCANdy! Urine – calcium oxalate crystals

Photo courtesy of Dr. Stephen Bonsib. #renal #pathology #kidneypath

A sample from the pathology teaching slide set on IgA Nephropathy, jointly prepared by Arkana Laboratories and @goKDIGO. http://KDIGO.org/guidelines/gd/

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2/Ultrastructural examination showed mesangial deposits, in addition to subepithelial and intramembranous deposits. PLA2R. THSD7A, NELL1 and EXT2 stains were negative. The presence of mesangial deposits favors a secondary MN, likely a recurrence of this patient's original disease.

1/The image shows finely granular C4d staining along the glomerular capillary walls. IgG, kappa and lambda were also positive, in the same distribution. These findings are consistent with membranous nephropathy.
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Nasr SH et al. DNAJB9 Is a Specific Immunohistochemical Marker for Fibrillary Glomerulonephritis. Kidney Int Rep. 2017 Aug 8;3(1):56-64. PMID: 29340314

DNAJB9 expression, which is typically seen in cases of fibrillary glomerulopathy, is not detected in immunotactoid glomerulopathy (see reference).

The differential diagnosis of immunotactoid glomerulopathy includes other glomerular diseases associated with organized deposits, including cryoglobulinemic glomerulonephritis, fibrillary glomerulopathy, and amyloidosis.

Of note, there is a strong association between immunotactoid glomerulopathy and underlying lymphoproliferative disease.

Immunofluorescence findings may include IgG deposits and light chain restriction (kappa more often than lambda). Figure 2 shows the microtubule deposits seen by electron microscopy. These tubular type deposits characteristically show hollow centers with at least some degree of parallel arrangement.

Figure 1 shows characteristic glomerular changes seen with Masson trichrome staining, including capillary wall thickening, capillary proliferation, mesangial matrix expansion, glomerular tuft lobulation, and fuchsinophilic capillary wall deposits.

Immunotactoid glomerulopathy is one of many glomerular diseases characterized by organized deposits. 

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This is the C4d immunofluorescence from a 5y post-transplant biopsy of an AA female who had ESRD due to lupus nephritis. What is your diagnosis?

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The study suggests doctors should test for HTRA1 in older patients when standard tests don't find a cause, since identifying the actual problem helps determine the right treatment. #renalpath #nephsky #pathsky

Doctors usually test for known causes, but those tests often come back negative in older patients. Researchers looked at kidney biopsies from three groups of patients and found HTRA1 in about 1 in 5 patients over 80, compared to only 2% in younger patients.

This study found that HTRA1 is a common cause of membranous nephropathy in patients over 80 years old. Membranous nephropathy is a kidney disease where the immune system attacks the kidney's filtering system, causing protein to leak into the urine.