madras medicalcollege renal biopsy analyses

1. RENAL BIOPSY
ANALYSIS-2018

2. Trend over last 3 years
490
661
442
0
100
200
300
400
500
600
700
2016 2017 2018
No.of biopsy

3. Total Number of Biopsies
Native, 358, 81%
Allograft , 77, 17%
preimplantation, 7, 2%
Renal biopsy-442
Native Allograft preimplantation

4. Biopsy adequacy
Number of glomeruli : 20±9 (Mean)

5. Gender
Male, 112, 50%
Female , 111, 50%
GENDER
Male
Female

6. 29
31
28
24
29
26
35
31
35
20
24 23
12
2
3
4
13
3
6
3
7
10
4
3
2
3
2
JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER
MONTH-WISE
Native kidney allograft protocol

7. Native kidney biopsy

8. 18, 8%
185, 83%
16, 7%
4, 2%
20, 9%
AGE WISE-NATIVE KIDNEY
<15
15-60
60-70
70-80

9. RPRF, 40, 18%
AKI, 17, 8%
NEPHROTIC SYDROME, 52,
23%
SUB NEPHROTIC
PROTEINURIA, 5, 2%
CKD, 3, 1%
ACUTE NEPHRITIC
SYNDROME, 13, 6%
ACUTE ON CKD, 6, 3% SLE, 39, 18%
NEPHROTIC PROTEINURIA,
12, 5%
NEPHROTIC SYNDROME WITH
AKI, 12, 5%
SNAKE BITE AKI, 4, 2%
OBSTERTRIC AKI, 6, 3%
RENAL FAILURE
UNCLASSIFIED, 14, 6%
CLINICAL SYNDROMES

10. DIAGNOSIS NUMBER
SLE 39 (17.5%)
IRGN 26 (11.6%)
MCD 23 (10.3%)
MN 23 (10.3%)
IgAN 17 (7.6%)
FSGS 15 (6.7%)
CKD-U 10 (4.4%)
ATI 9 (4%)
Diabetic nephropathy 8 (3.6%)
Anti-GBM 7 (3.1%)
AIN 7 (3.1%)
TMA 7 (3.1%)

11. DIAGNOSIS NUMBER
ANCA Vasculitis 7 (3.1%)
MPGN 6 (2.7%)
Multiple Myeloma 4 (1.8%)
Renal cortical necrosis 3 (1.3%)
Hypertension Nephrosclerosis 3 (1.3%)
CKD 2 (0.9%)
Malignant hypertension 2 (0.9%)
Collapsing GN 2 (0.9%)
C3 GN /DDD 2 (0.9%)
Acute pyelonephritis 2 (0.9%)
Amyloidosis 1(0.4%)

12. MCD, 23, 26%
FSGS, 15, 17%
MN, 23, 26%
IgAN, 17, 20%
MPGN, 6, 7%
C3 GN/DDD, 2, 2%
COLLAPSING GN, 2, 2%
PRIMARY GLOMERULAR DISEASE

13. SLE, 39, 45%
IRGN, 25, 29%
DIABETIC NEPHROAPTHY, 8,
9%
AMYLOIDOSIS, 1, 1%
ANTI GBM, 7, 8% ANCA, 7, 8%
SECONDARY GLOMERULAR DISEASES

14. ATI, 9, 36%
AIN, 7, 28%
CAST NEPHROAPTHY, 4, 16%
CKD-U, 5, 20%
TUBULO-INTERSTITIAL DISEASE

15. TMA, 7, 54%
HYPERTENSION RELATED, 6,
46%
VASCULAR DIESEASE

16. LUPUS NEPHRITIS-39
MALE, 3, 8%
FEMALE, 36, 92%
GENDER

17. LUPUS NEPHRITIS
<15, 5, 13%
15-45, 34, 87%
>45, 0, 0%
AGE
<15 15-45 >45

18. 1 1
4
12 12
8
1
0
2
4
6
8
10
12
14
CLASS 1 CLASS 2 CLASS 3 CLASS 4 CLASS 3/4 + 5 CLASS 5 CLASS 6
LUPUS NEPHRITIS-CLASS DISTRIBUTION

19. 1 1
5
6
4
7
0
0
1
2
3
4
5
6
7
8
class 1 class 2 class 3 class 4 class 5 class 3/4+5 class 6
NEWLY DETECTED SLE

20. LUPUS NEPHRITIS
■ INDICATION FOR BIOPSY:
Newly detected lupus nephritis-24
Proteinuric relapse-7
refractory lupus nephritis-5
chronic kidney disease-3
Proteinuric relapse:
5 patients class IV  IV (A+C)-2
IV (A)+V-3
1 Patient class IV+V  IV(A+C) + V
1 Patient class III  V
Among 5 refractory lupus nephritis only one patient had class switch from
IV(A)IV(A) +V

21. LUPUS NEPHRITIS
■ Full house pattern- 35 (89.7%)
■ At least one crescent in biopsy-13(33.3%)
■ Crescentic GN- 2
■ TMA-1

22. IRGN-26
MALE , 15, 58%
FEMALE, 11, 42%
GENDER

23. IRGN
<15, 2, 8%
15-30, 3, 11%
30-60, 19, 73%
>60, 2, 8%
AGE

24. IRGN
RPRF, 10, 38%
AKI, 2, 8%
NEPHROTIC SYNDROME, 4,
15%
SUBNEPHROTIC, 1, 4%
NEPHRITIC, 5, 19%
ACUTE ON CKD, 2, 8%
NS with AKI, 1, 4%
RENAL FAILURE
UNCLASSIFIED, 1, 4%
CLINICAL PRESENTATION

25. IRGN-IF PATTERN
60
24
16
4
50
12
31
2
0
10
20
30
40
50
60
70
C3 DOMINANT C3+C1Q C3 FULL HOUSE
2018
2017

26. IRGN
■ 40% patients had atleast one crescent.
■ Crescentic GN was observed in 2 patient.
■ 24 % were diabetic and out of 6 patients 4 had co-existing diabetic nephropathy.
■ Most common differential diagnosis was SLE followed by C3GN.
■ Cellulitis was the most common documented infection.
■ IFTA: 0-25%- 24%
25-50%-12%
50-75%-4%
NO IFTA-60%

27. Minimal change disease-23
male, 14, 61%
female, 9, 39%
gender

28. MCD
13, 56%
8, 35%
2, 9%
age
<18 18-60 >60

29. MCD
NEPHROTIC SYNDROME, 18,
78%
SUB-NEPHROTIC
PROTEINURIA, 1, 4%
NEPHROTIC PROTEINURIA, 2,
9%
NEPHROTIC SYNDROME WITH
AKI, 2, 9%
CLINICAL PRESENTATION

30. MCD
■ 5 patients(21.7%) had 25-50% IFTA
■ 5 patients had SDNS and 1 patient infrequent relapse/SSNS

31. Membranous Nephropathy-23
MALE, 15, 65%
FEMALE, 8, 35%
GENDER

32. MN
<15, 0, 0% 15-30, 2, 9%
30-60, 14, 61%
>60, 7, 30%
AGE
<15
15-30
30-60
>60

33. MN
NEPHROTIC SYNDROME, 13,
59%
NEPHROTIC PROTEINURIA, 3,
14%
SUBNEPHROTIC, 2, 9%
NS WITH AKI, 2, 9%
RPRF, 2, 9%
CLINICAL PRESENTATION

34. MN
■ 1 patient had crescentic transformation
■ IFTA:
0-25%- 4
25-50%-3
75-100%-1
NO IFTA-15
NATIVE MEDICATION : 6 (26%)
Stage 1 membranous nephropathy: 4 (17%)

35. IgA nephropathy-17
MALE, 12, 71%
FEMALE, 5, 29%
GENDER

36. IgAN
<15, 1, 6%
15-30, 9, 53%
30-60, 7, 41%
AGE

37. IgAN
RPRF, 6, 35%
AKI, 1, 6%
NEPHROTIC SYNDROME, 2,
12%
NEPHRITIC SYNDROME, 3,
17%
NEPHROTIC PROTEINURIA, 1,
6%
NS WITH AKI, 3, 18%
OBSTETRIC AKI, 1, 6%
CLINICAL PRESENTATION

38. IgA-oxford classification:
Subtype number
M1 EO SO TO-CO 1
M1 E1 SO TO-CO 2
M1 E1 S1 TO-C0 2
M1 E1 S1 T1-C1 2
M1 E1 S0 T1-C2 1
M1 EO S1 TO-C0 3
M1 E0 S1 T1- C0 1
M1 E1 S1 TO- C1 1
Advance IgA nephropathy 4

39. IgAN
■ IgA vasculitis-2
■ Crescentic IgA nephropathy-1.
■ IFTA:
0-25%-5
25-50%-5
50-75%-1
75-100%-1
NO IFTA-5

40. FSGS-15
MALE, 9, 60%
FEMALE, 6, 40%
GENDER

41. FSGS
<15, 0, 0%
15-30, 6, 40%
>30, 9, 60%
AGE

42. FSGS
AKI, 1, 6%
NEPHROTIC SYNDROME, 6,
40%
SUBNEPHROTIC, 1, 7%
NEPHRITIC, 1, 7%
NEPHROTIC PROTEINURIA, 2,
13%
NS WITH AKI, 3, 20%
OBSTETRIC AKI, 1, 7%
CLINICAL PRESENTATION

43. FSGS
■ VARIANT: NOS -14/15, TIP-1/15
■ IFTA:
0-25%-7
25-50%-3
NO IFTA-5

44. CKD-U:10
Male, 6, 60%
Female, 4, 40%
GENDER

45. CKD-U
15-30, 2, 20%
30-60, 8, 80%
AGE

46. CKD-U
RPRF, 1, 9%
AKI, 2, 18%
CKD, 2, 18%
ACUTE ON CKD, 2, 18%
OBSTETRIC AKI, 1, 9%
RENAL FAILURE
UNCLASIFFIED, 3, 28%
CLINICAL PRESENTATION

47. CKD-U
1
2
1
6
0
1
2
3
4
5
6
7
0-25% 25-50% 50-75% 75-100%
IFTA

48. CKD-U
■ 7 patients had hypertension with severe arteriosclerosis
■ 1 patient had diabetes for 3 years.
■ 3 patients were non hypertensive.
■ 1 patient had renal failure during first pregnancy with cystically dilated medullary
tubules.

49. ACUTE TUBULAR INJURY-9
MALE, 7, 78%
FEMALE, 2, 22%
GENDER

50. ACUTE TUBULAR INJURY
15-30, 0, 0%
30-60, 6, 67%
>60, 3, 33%
AGE

51. ACUTE TUBULAR INJURY
RPRF, 2, 22%
AKI, 3, 34%
SNAKE BITE AKI, 2, 22%
RENAL FAILURE
UNCALSSIFIED, 2, 22%
INDICATION

52. ACUTE TUBULAR INJURY
■ Pigment cast in 2 patients-myoglobin stain negative in one patient.
■ Fever with AKI-3 patients.
■ 1 patient had RVD with on ATT & ART.

53. Diabetic nephropathy-8
15-30, 0, 0%
30-60, 11, 79%
>60, 3, 21%
AGE

54. Diabetic nephropathy
MALE, 9, 64%
FEMALE, 5, 36%
Gender

55. DN
RPRF, 7, 50%
NEPHROTIC SYNDROME, 1, 7%
ACUTE ON CKD, 2, 14%
NEPHROTIC PROTEINURIA, 3,
22%
RENAL FAILURE
UNCLASSIFIED, 1, 7%
CLINICAL INDICATION

56. DN
■ Primary diagnosis: 8/14
■ Secondary diagnosis: 6/14( 5-IRGN ,1-AIN)
RPS CLASSIFIACTION:
Class 2A -2
Class 2B -5
Class 3 -5
Class 4 -2

57. Anti-GBM-7 CASES
male, 4,
57%
female,
3, 43%
gender
15-30, 4, 57%
30-60, 2, 29%
60-80, 1, 14%
Age
RPRF, 5,
72%
AKI, 1, 14%
NEPHRITIC
SYNDROME, 1,
14%
clinical presentation

58. ANTI-GBM
■ Atypical Anti-GBM:
case 1: TMA with linear IgA staining.
case 2:indolent course-creatinine stabilized at 1.9 mg/dl
case 3: presented as renal failure unclassified-CKD with moderate IFTA.
Segmental fibrinoid necrosis in 2 patients.

59. Acute interstitial nephritis
 7 cases-(M-3 , F-4)
 Indication- MC-renal failure unclassified(3 cases)
snake bite AKI(1)
SLE(1) , RPRF(1), AKI(1)
 1 patient scrub typhus +
 1 patient suspected sarcoid.
 1 patient –possible IGG4 disease.

60. TMA
 Males-2, females-5
 INDICATIONS: RPRF-2
AKI-2
SLE-1
Obstertic AKI-1
Renal failure unclassified-1
 CAUSES:
Acute pancreatitis-2
FSGS(peri-hilar variant)-1
Primi with abruption-1
Recurrent pregnancy loss with renal failure-1
SLE-1
Malignant hypertension-1

61. MPGN
■ 6 cases
■ Male-4 , female-2
■ Age(17-55)
■ Indication of biopsy: RPRF-4 , NS-2
IF:
Full house pattern-2
C3 dominant-2
Light chain restriction-1
IgG with C3-1

62. MPGN
■ Crescents in 2 patients(C3/IRGN-1,C3/DDD-1)
■ DIAGNOSIS:
• SLE-2 patients.
• ?CRYO-1
• C3GN/DDD-1
• C3GN/IRGN-1
• Hepatits B-1

63. Monoclonal gammapathy
Male-4 , female-1
Indication: AKI-3, Renal failure unclassified-1, RPRF-1
Diagnosis: Cast nephropathy-3 ( lambda-2, kappa-1)
light chain deposition disease-1
light chain proximal tubulopathy-1
acute tubular injury(lambda light chain restriction over tubular epithelial cells).
MPGN IgM and Kappa light chain positive over mesangium( suspected
cryoglobulinemia)

64. ANCA VASCULITIS
7 CASES.
Pauci-immune:2
Superimposed ANCA on IC- crescentic GN-2
Superimposed ANCA on anti-GBM-2
Membranous nephropathy with crescentic transformation-1

65. Renal cortical necrosis
■ 3 patients
Case1: 16/M had RTA-presented with anuric failure-cortical necrosis-entire cortex and
medulla coagulative necrosis. CT renal angio-normal .Cause –unknown.
Case 2: 25/F presented with postpartum AKI. 40-50% cortex necrotic.
Case3 : 50/M , snake bite-AKI- >75% cortex necrotic.large areas of haemorrhage in
necrotic interstitum.

66. Collapsing GN
CASE1 : 30/M with recurrent episodes of macroscopic hematuria and polyarthirits.
Renal failure with nephrotic proteinuria.C3(2+) non specific staining over glomerular
tuft. ? Parvovirus / still’s disease.
CASE 2: 58/M , presented with nephrotic syndrome with AKI.segmental staining of C3
in one glomerulus.

67. C3GN/DDD
 CASE 1: 17/m , presented with nephrotic syndrome and normal renal function.
LM-MPGN. IF- C3 granular to pseudolinear positivity over capillary loops and
mesangium.
 CASE 2: 47/F , presented with nephrotic syndrome with normal renal function.

68. SPECIAL POPULATIONS

69. GERIATRIC BIOPSY(20)
MALE, 17, 85%
FEMLAE, 3,
15%
GENDER
60-70, 17, 85%
70-80, 3, 15%
AGE SUBGROUP

70. GERIATRIC BIOSPY
RPRF, 5, 25%
AKI, 2, 10%
NEPHROTIC SYNDROME, 6,
30%
ACUTE IN CKD, 1, 5%
NEPHROTIC PROTEINURIA, 1,
5%
NS WITH aki, 2, 10%
SNAKE BITE , 1, 5%
RENAL FAILURE
UNCLASSIFIED, 2, 10%
CLINICAL PRESENTATION

71. GERIATRIC BIOPSY
MCD, 2, 10%
MN, 7, 35%
ANTI-GBM, 1, 5%
IRGN, 2, 10%
ATI, 3, 15%
AIN, 1, 5%
MM, 3, 15%
ANCA VASCULITIS, 1, 5%
DIAGNOSIS

72. POST PARTUM BIOSPY(8)
AKI, 6, 75%
NEPHROTIC
SYNDROME,
2, 25%
INDICATION
FSGS, 1, 12%
MN, 1, 12%
MPGN, 1,
12%
IGA, 1, 12%
TMA, 1, 13%
CKD-U, 1,
13%
MHT, 1, 13%
RCN, 1, 13%
DIAGNOSIS

73. SNAKE BITE AKI(4)
ATI, 2, 50%
AIN, 1, 25%
RCN, 1, 25%
DIAGNOSIS

74. SPECIAL STUDIES
■ EM study-11
■ M-PLA2R-4
■ IHC-3

75. EM-11
Established, 1, 9%
SUPPORTED THE
DIAGNOSIS, 7, 64%
DID NOT HELP, 3, 27%
IMPACT

76. EM
■ Established the diagnosis-1
-Thin basement membrane disease.
■ Supported the diagnosis-7( IRGN -3,C3GN-2, MN-1)
■ Did not help-3.

77. Others
■ M-PLA2R-(3+ ,1 -)
■ IHC:
Myoglobin-1-negative
Adenovirus-1-negative
BK virus (SV40)-negative
LECT-2 & SAA-negative.

78. Allograft biopsy

79. PRE-IMPLANATION BIOSPY
4
2
1
PRE-IMPLANATION BIOPSIES-7
ATI
NORMAL
IgAN

80. Allograft biopsy
■ Total no of biopsy-76.
male , 58, 76%
female, 18,
24%
GENDER

81. 0
35
41
0
5
10
15
20
25
30
35
40
45
<15 15-30 30-60
Age group
Age distribution

82. ACMR, 22, 29%
ABMR+ACR, 19, 25%
CNI TOX, 4, 5%
ATI, 15, 20%
RECURRENT GN, 3, 4%
TG, 1, 2%
CORTICAL NECROSIS, 1, 1%
TMA, 6, 8%
COLLAPSING GN, 2, 3%
AIN, 1, 1% CKD, 1, 1%
NORMAL, 1, 1% DIAGNOSIS
ACMR ABMR+ACR CNI TOX ATI RECURRENT GN TG CORTICAL NECROSIS TMA COLLAPSING GN AIN CKD NORMAL

83. ACMR
17
1
2
0 0
2
0
2
4
6
8
10
12
14
16
18
BANFF 1A BANFF 1B BANFF 2A BANFF 2B BANFF 3 BORDERLINE
SEVERITY OF ACMR

84. Timing of ACMR
9
13
0
2
4
6
8
10
12
14
EARLY(3 MONTHS) LATE(> 3 MONTHS)

85. ABMR
■ All cases associated with borderline ACR but not satisfying Mixed rejection.
■ ALL cases were C4d +
2
17
0
2
4
6
8
10
12
14
16
18
EARLY ABMR LATE ABMR

86. Glomerular disease in graft
■ IgA nephropathy-4
■ Superimposed ANCA/Anti-GBM disease in a combined ACR+ABMR-1
■ Post transplant FSGS-1

87. Post-transplant TMA:
MALES
50%
FEMALES
50%
GENDER
2
3
2
0
0.5
1
1.5
2
2.5
3
3.5
<1 WEEK UPTO 3 MONTHS >3 MONTHS
TIME PERIOD
NK
50%
SLE
16%
VUR/NB
17%
DONOR DERIVED
17%
Native kidney disease

88. POST TRANSPLANT COLLAPSING GN
2 CASES
■ CASE 1: 25/m , NKD: ? CGN. Post transplant-3 years-graft dysfunction-collapsing
GN+combined ACMR + acute ABMR.
■ CASE 2: 29/m, NKD: ? CGN. Post transplant -3 years-graft dysfunction-collapsing
GN+IgA nephropathy

89. Graft nephrectomy-7
TRA-
pseudoaneurys
m rupture
29%
TRA-
THROMBOSIS
29%
TRAS
14%
TMA
14%
GRAFT
RUPTURE
14%
Indication
30 DAYS
86%
> 30 DAYS
14%
TIME

90. COMPLICATIONS

91. COMPLICATIONS
■ Perinephric hematoma-3
■ Graft nephrectomy due to complications- nil
■ Surgical intervention-nil

92. THANK YOU