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BDIAP Sri Lankan School of Pathology 2017
Renal biopsy slide seminar
Prof Ian Roberts
Case 1
Female, 76 years. Progressive chronic kidney disease, creatinine 71 to 172 micromol/l over the past 5 years. Two episodes of acute kidney injury this year in the setting of diverticulitis and C diff colitis. Haematuria and proteinuria 5g/day. Albumin 25 g/l. IgG kappa paraprotein (12g). Free light chain ratio 2.4.
 
IF: Glomeruli negative for IgG, IgA, IgM, C3, C1q and light chains. Tubular resorption droplets strongly positive for kappa, weakly positive for lambda.
 
IP: Kappa slide provided, lambda negative in glomeruli and tubules. IgG and C4d see images 
Case 1 H&E
Case 1 PAS
Case 1 silver
Case 1 kappa
Case 1 IgG
Case 1 C4d
Case 1 EM1
Diagnosis & discussion [0]
Case 2
Female, 71 years. Multifocal lesions on brain MRI + confusion. Protein and blood in urine. Kidney heterogenous on CT scan. ANCA/antiGBM negative.
 
IF: Negative for IgG, IgA, IgM, C3, C1q, kappa and lambda. 
Case 2 H&E
Diagnosis & discussion [0]
Case 3
Male, 66 years. Metallic aortic valve replacement 6 months ago. Nephrotic syndrome, 7g proteinuria, albumin 24 g/l. 3+ haematuria. Creatinine 200 micromol/l. Acute screen negative apart from low titre antiGBM.
 
IF: IgG (3+) and lambda (3+), linear and focal granular GBM + mesangial, see images, and 1+ linear TBM. IgA (1+) linear GBM and TBM, IgM negative. C3 (2+) and C1q (2+) linear and focal granular GBM + mesangial, TBM negative. Kappa (1+) linear GBM and TBM.
Case 3 H&E
Case 3 silver
Case 3 IgG
Case 3 lambda
Case 3 EM1
Case 3 EM2
Case 3 EM3
Case 3 EM4
Diagnosis & discussion [0]
Case 4
Male, 62 years. Stable myeloma. Increase in creatinine to 126 micromol/l. Urine protein 0.24 g/day. Free serum kappa light chain. Bone marrow 6% atypical plasma cells.
 
IP: IgG and kappa, see images. IgA, IgM and lambda negative in glomeruli. 
Case 4 H&E
Case 4 silver
Case 4 PAS
Case 4 Trichro­me
Case 4 IgG
Case 4 kappa
Case 4 EM1
Case 4 EM2
Case 4 EM3
Case 4 EM4
Case 4 EM5
Case 4 EM6
Diagnosis & discussion [0]
Case 5
Male, 44 years. Acute kidney injury. Complete anuria for 4 days preceded by frank haematuria. Purpuric rash. Creatine kinase >10,000. Monoclonal band (IgG kappa). AntiGBM negative.
 
IF: IgG see image. IgA, IgM, C3, C1q, light chains negative. 
Case 5 H&E
Case 5 silver
Case 5 PAS
Case 5 IgG
Diagnosis & discussion [0]
Case 6
Male, 78 years. New onset renal dysfunction. Creatinine 214 micromol/l. 11g proteinuria. Active sediment. IgG lambda paraprotein. 
 
IF: C3 see image. IgG, IgA, IgM, C1q, light chains negative. 
Case 6 H&E
Case 6 silver
Case 6 PAS
Case 6 C3
Case 6 EM1
Case 6 EM2
Case 6 EM3
Case 6 EM4
Diagnosis & discussion [0]
Case 7
Male 64 years. Declining renal function. Creatinine 291 to 361 micromol/l. UPCR 113. Mild hydronephrosis. Recent stents for ureteric thickening. Central diabetes insipidus.

IF: Negative for IgG, IgA, IgM, C3, C1q and light chains. 
Case 7 H&E
Case 7 PAS
Diagnosis & discussion [0]
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