DZI20-202-Case-14

Sequence	Case	Clinical history	Diagnosis
1	DZI20-202-Case-1 DZI20-202-Case-1	donor biopsy	FROZEN SECTION DIAGNOSIS #1 AND 1B; (LEFT KIDNEY BIOPSY): Renal parenchyma with few sclerosed glomeruli and mild interstitial fibrosis (see attached sheet) The attached sheet shows following report: LEFT KIDNEY: Number of glomeruli: 67 (permanents - 72) Number of sclerosed glomeruli: 6 (permanents - 0) Percentage of glomerular sclerosis: 9% (permanents - 0%) Tubular interstitial fibrosis/tubular atrophy: 1+ Vessel Arteriosclerosis: 1+ Vessel Hyalinosis: 0 (permanent - "occasional") COMMENT: Both the biopsies are subcapsular and may be more fibrotic than the remainder of the kidney. Permanent: KIDNEY (DONOR, LEFT), WEDGE BIOPSY (NEOB ADKY401): CHRONIC GLOMERULAR ENDOTHELIAL INJURY WITH MINIMAL MESANGIAL DEPOSITS, Note: Permanent and deeper sections from A show a wedge of frozen cortical tissue with about 72 glomeruli, of which none is globally sclerotic. Many glomeruli show segmental thickening of capillary walls, one with global duplication. All glomeruli show intracapillary mononuclear cells. There is mild to moderate mesangial expansion in most glomeruli. Adhesions, crescents, necrosis and thrombi are not present. Fibrosis and tubular atrophy affect about 5-10% of the cortical area. The remainder of the tubules is back to back. There is no interstitial inflammation. Many arteries are present, a few with mild intimal fibrosis. Arterioles show occasional hyalinosis. Vasculitis and thrombi are not present. Permanent and deeper sections from B show a wedge of frozen cortical tissue with about 80 glomeruli, of which 4 are globally sclerotic. Many glomeruli show segmental thickening of capillary walls, some with segmental duplication. All glomeruli show intracapillary mononuclear cells. There is mild to moderate mesangial expansion in most glomeruli. Adhesions, crescents, necrosis and thrombi are not present. Fibrosis and tubular atrophy affect about 10% of the cortical area. The remainder of the tubules is back to back. A few tubules contain intratubular protein casts. Focal subcapsular inflammation is present. Many arteries are present, a few with mild intimal fibrosis. Arterioles show occasional hyalinosis. Vasculitis and thrombi are not present. One slide labeled S16-78415 NEOB, ADKY401 FX showed similar findings as in frozen biopsy report. Frozen tissue re-processed for electron microscopy shows segmental effacement of podocyte foot processes. There is segmental basement membrane duplication associated with wrinkling of capillary loops, new membrane formation and mesangial cell interposition. Evaluation of endothelial areas is limited by artifact. Minimal mesangial and para-mesangial electron dense deposits are present. In summary, the biopsy shows chronic glomerular endothelial injury characterized by basement membrane duplication. In addition, there are minimal mesangial deposits by electron microscopy. These findings suggest chronic endothelial injury from chronic thrombotic microangiopathy or mild chronic immune complex glomerular disease. Correlation with clinical findings including prothrombotic or coagulopathic states is recommended. FROZEN SECTION DIAGNOSIS #1 AND 1B; (LEFT KIDNEY BIOPSY): Renal parenchyma with few sclerosed glomeruli and mild interstitial fibrosis (see attached sheet) The attached sheet shows following report: LEFT KIDNEY: Number of glomeruli: 67 (permanents - 72) Number of sclerosed glomeruli: 6 (permanents - 0) Percentage of glomerular sclerosis: 9% (permanents - 0%) Tubular interstitial fibrosis/tubular atrophy: 1+ Vessel Arteriosclerosis: 1+ Vessel Hyalinosis: 0 (permanent - "occasional") COMMENT: Both the biopsies are subcapsular and may be more fibrotic than the remainder of the kidney. Permanent: KIDNEY (DONOR, LEFT), WEDGE BIOPSY (NEOB ADKY401): CHRONIC GLOMERULAR ENDOTHELIAL INJURY WITH MINIMAL MESANGIAL DEPOSITS, Note: Permanent and deeper sections from A show a wedge of frozen cortical tissue with about 72 glomeruli, of which none is globally sclerotic. Many glomeruli show segmental thickening of capillary walls, one with global duplication. All glomeruli show intracapillary mononuclear cells. There is mild to moderate mesangial expansion in most glomeruli. Adhesions, crescents, necrosis and thrombi are not present. Fibrosis and tubular atrophy affect about 5-10% of the cortical area. The remainder of the tubules is back to back. There is no interstitial inflammation. Many arteries are present, a few with mild intimal fibrosis. Arterioles show occasional hyalinosis. Vasculitis and thrombi are not present. Permanent and deeper sections from B show a wedge of frozen cortical tissue with about 80 glomeruli, of which 4 are globally sclerotic. Many glomeruli show segmental thickening of capillary walls, some with segmental duplication. All glomeruli show intracapillary mononuclear cells. There is mild to moderate mesangial expansion in most glomeruli. Adhesions, crescents, necrosis and thrombi are not present. Fibrosis and tubular atrophy affect about 10% of the cortical area. The remainder of the tubules is back to back. A few tubules contain intratubular protein casts. Focal subcapsular inflammation is present. Many arteries are present, a few with mild intimal fibrosis. Arterioles show occasional hyalinosis. Vasculitis and thrombi are not present. One slide labeled S16-78415 NEOB, ADKY401 FX showed similar findings as in frozen biopsy report. Frozen tissue re-processed for electron microscopy shows segmental effacement of podocyte foot processes. There is segmental basement membrane duplication associated with wrinkling of capillary loops, new membrane formation and mesangial cell interposition. Evaluation of endothelial areas is limited by artifact. Minimal mesangial and para-mesangial electron dense deposits are present. In summary, the biopsy shows chronic glomerular endothelial injury characterized by basement membrane duplication. In addition, there are minimal mesangial deposits by electron microscopy. These findings suggest chronic endothelial injury from chronic thrombotic microangiopathy or mild chronic immune complex glomerular disease. Correlation with clinical findings including prothrombotic or coagulopathic states is recommended.
2	DZI20-202-Case-2 DZI20-202-Case-2	donor kidney bx	FROZEN SECTION DIAGNOSIS #1; (RIGHT KIDNEY): Number of glomeruli: 51, Number of sclerous glomeruli: 2, Percentage of glomeruli sclerosis: 3.9%, (permanent 10%) Tubular interstitial fibrosis/tubular atrophy: 0 (permanent 15%) Vessel arteriosclerosis: 0 Vessel hyalinosis: 0. Interstitial nephritis in a predominantly subcapsular distribution. FROZEN SECTION DIAGNOSIS #2; (LEFT KIDNEY): Number of glomeruli: 48. Number of sclerosed glomeruli: 3. Percentage of glomeruli sclerosis: 6.25% (permanent - 11%) Tubular interstitial fibrosis/tubular atrophy: 0 (permanent - 10%) Vessel arteriosclerosis: 0 Vessel hyalinosis: 0. Patchy interstitial nephritis. Note: The frozen section slides were reviewed and the findings were compared with the permanent section of the remnant showing comparable findings. The variation is due to better sampling with some findings more readily apparent on the stained permanent sections. Such variation is of no clinical significance. FROZEN SECTION DIAGNOSIS #1; (RIGHT KIDNEY): Number of glomeruli: 51, Number of sclerous glomeruli: 2, Percentage of glomeruli sclerosis: 3.9%, (permanent 10%) Tubular interstitial fibrosis/tubular atrophy: 0 (permanent 15%) Vessel arteriosclerosis: 0 Vessel hyalinosis: 0. Interstitial nephritis in a predominantly subcapsular distribution. FROZEN SECTION DIAGNOSIS #2; (LEFT KIDNEY): Number of glomeruli: 48. Number of sclerosed glomeruli: 3. Percentage of glomeruli sclerosis: 6.25% (permanent - 11%) Tubular interstitial fibrosis/tubular atrophy: 0 (permanent - 10%) Vessel arteriosclerosis: 0 Vessel hyalinosis: 0. Patchy interstitial nephritis. Note: The frozen section slides were reviewed and the findings were compared with the permanent section of the remnant showing comparable findings. The variation is due to better sampling with some findings more readily apparent on the stained permanent sections. Such variation is of no clinical significance.
3	DZI20-202-Case-3 DZI20-202-Case-3	donor bx	A. DONOR KIDNEY PRETRANSPANT WEDGE BIOPSY SLIDE UNOS ADDQ091: ACUTE TUBULAR INJURY TOTAL GLOMERULI 77; TWO WITH INTRACAPILLARY FIBRIN PERCENT GLOBAL GLOMERULOSCLEROSIS 2.6% SMALL ARTERIES: 2 NORMAL ARTERIOLES: NORMAL TUBULES: CASTS WITH RPOTEIN, DEBRIS, AND DYSTROPHIC CALCIFICATIONS INTERSTITIAL FIBROSIS/TUBULAR ATROPHY: < 5% A. DONOR KIDNEY PRETRANSPANT WEDGE BIOPSY SLIDE UNOS ADDQ091: ACUTE TUBULAR INJURY TOTAL GLOMERULI 77; TWO WITH INTRACAPILLARY FIBRIN PERCENT GLOBAL GLOMERULOSCLEROSIS 2.6% SMALL ARTERIES: 2 NORMAL ARTERIOLES: NORMAL TUBULES: CASTS WITH RPOTEIN, DEBRIS, AND DYSTROPHIC CALCIFICATIONS INTERSTITIAL FIBROSIS/TUBULAR ATROPHY: < 5%
4	DZI20-202-Case-4 DZI20-202-Case-4	donor bx	A. KIDNEY DONOR SLIDE(X2 UNOS ADKD348) PRE TRANSPLANT BIOPSY: MILD TUBULAR INJRY NUMBER OF GLOMERULI: ~100 PERCENT GLOBAL GLOMERULOSCLEROSIS: 1% ARTERIES: MODERATE ARTERIOSCLEROSIS INTERSTITIUM: MILD TUBULAR ATROPHY AND INTERSTITIAL FIBROSIS ~5% ADEQUATE SPECIMEN WITH MANY GLOMERULI AND SMALL ARTERIES A. KIDNEY DONOR SLIDE(X2 UNOS ADKD348) PRE TRANSPLANT BIOPSY: MILD TUBULAR INJRY NUMBER OF GLOMERULI: ~100 PERCENT GLOBAL GLOMERULOSCLEROSIS: 1% ARTERIES: MODERATE ARTERIOSCLEROSIS INTERSTITIUM: MILD TUBULAR ATROPHY AND INTERSTITIAL FIBROSIS ~5% ADEQUATE SPECIMEN WITH MANY GLOMERULI AND SMALL ARTERIES
5	DZI20-202-Case-5 DZI20-202-Case-5	donor bx	FROZEN SECTION DIAGNOSIS #1; (RIGHT KIDNEY BIOPSY): Renal parenchyma with very minimal glomerulosclerosis (1%) and no interstitial fibrosis or arteriosclerosis. Number of glomeruli: 85 Number of sclerosed glomeruli: 1. Percentage of glomerulosclerosis: 1%. (permanent - 5%) Tubular interstitial fibrosis/tubular atrophy: 0. (permanent - 30-40%) Vessel arteriosclerosis: 0. Vessel hyalinosis: 0. FROZEN SECTION DIAGNOSIS #2; (LEFT KIDNEY BIOPSY): Renal parenchyma with no glomerulosclerosis and no interstitial fibrosis or arteriosclerosis. Number of glomeruli: 80 Number of sclerosed glomeruli: 0. Percentage of glomerulosclerosis: 0%. (permanent - 1%) Tubular interstitial fibrosis/tubular atrophy: 0. (permanent - 20%) Vessel arteriosclerosis: 0. Vessel hyalinosis: 0. FROZEN SECTION DIAGNOSIS #1; (RIGHT KIDNEY BIOPSY): Renal parenchyma with very minimal glomerulosclerosis (1%) and no interstitial fibrosis or arteriosclerosis. Number of glomeruli: 85 Number of sclerosed glomeruli: 1. Percentage of glomerulosclerosis: 1%. (permanent - 5%) Tubular interstitial fibrosis/tubular atrophy: 0. (permanent - 30-40%) Vessel arteriosclerosis: 0. Vessel hyalinosis: 0. FROZEN SECTION DIAGNOSIS #2; (LEFT KIDNEY BIOPSY): Renal parenchyma with no glomerulosclerosis and no interstitial fibrosis or arteriosclerosis. Number of glomeruli: 80 Number of sclerosed glomeruli: 0. Percentage of glomerulosclerosis: 0%. (permanent - 1%) Tubular interstitial fibrosis/tubular atrophy: 0. (permanent - 20%) Vessel arteriosclerosis: 0. Vessel hyalinosis: 0.
6	DZI20-202-Case-6 DZI20-202-Case-6	donor bx	KIDNEY, RIGHT (DONOR, PRE-TRANSPLANT), WEDGE BIOPSY: NO DIAGNOSTIC ABNORMALITIES RECOGNIZED, SEE NOTE. Note: One slide labeled UNOS ADEV297 RIGHT KIDNEY BIOPSY with tissue sections of a wedge of frozen cortical tissue shows about 81 glomeruli, of which none is globally sclerotic. Glomeruli appear generally unremarkable. Crescents, necrosis and intraluminal thrombi are not identified. There is no interstitial inflammation. There is no fibrosis or tubular atrophy. Some tubules are dilated and show focal loss of brush borders. Arteries and arterioles are unremarkable. Vasculitis and thrombi are not present. One slide from the New England Organ Bank labeled “S16-07420 Lowell General” show a wedge of cortical tissue with 79 glomeruli, of which 1 is globally sclerotic. Glomeruli appear generally unremarkable. Crescents, necrosis and intraluminal thrombi are not identified. There is no interstitial inflammation. There is no fibrosis or tubular atrophy. Tubules are back to back. Occasional protein casts, pigmented casts and calcifications are present in tubules focally. Arteries and arterioles are unremarkable. Vasculitis and thrombi are not present. KIDNEY, RIGHT (DONOR, PRE-TRANSPLANT), WEDGE BIOPSY: NO DIAGNOSTIC ABNORMALITIES RECOGNIZED, SEE NOTE. Note: One slide labeled UNOS ADEV297 RIGHT KIDNEY BIOPSY with tissue sections of a wedge of frozen cortical tissue shows about 81 glomeruli, of which none is globally sclerotic. Glomeruli appear generally unremarkable. Crescents, necrosis and intraluminal thrombi are not identified. There is no interstitial inflammation. There is no fibrosis or tubular atrophy. Some tubules are dilated and show focal loss of brush borders. Arteries and arterioles are unremarkable. Vasculitis and thrombi are not present. One slide from the New England Organ Bank labeled “S16-07420 Lowell General” show a wedge of cortical tissue with 79 glomeruli, of which 1 is globally sclerotic. Glomeruli appear generally unremarkable. Crescents, necrosis and intraluminal thrombi are not identified. There is no interstitial inflammation. There is no fibrosis or tubular atrophy. Tubules are back to back. Occasional protein casts, pigmented casts and calcifications are present in tubules focally. Arteries and arterioles are unremarkable. Vasculitis and thrombi are not present.
7	DZI20-202-Case-7 DZI20-202-Case-7	donor bx	DONOR KIDNEY BIOPSY (RIGHT): NO DIAGNOSTIC ABNORMALITY RECOGNIZED, SEE NOTE. NOTE: The wedge biopsy contains about 100 glomeruli all of which are normal, as are the tubules, vessels and interstitium. There is no evidence of acute or chronic injury. A core biopsy with 10 glomeruli shows similar features (one glomerulus is globally sclerotic. DONOR KIDNEY BIOPSY (RIGHT): NO DIAGNOSTIC ABNORMALITY RECOGNIZED, SEE NOTE. NOTE: The wedge biopsy contains about 100 glomeruli all of which are normal, as are the tubules, vessels and interstitium. There is no evidence of acute or chronic injury. A core biopsy with 10 glomeruli shows similar features (one glomerulus is globally sclerotic.
8	DZI20-202-Case-8 DZI20-202-Case-8	donor bx	DONOR KIDNEY BIOPSY, LEFT (FROZEN SECTION): ARTERIOSCLEROSIS, SEE NOTE. NOTE: The 2 frozen sections of a wedge cortical biopsy stained with H&E show a total of about 63 glomeruli of which 3 are globally sclerotic (5%). The glomeruli show no evidence by light microscopy of diabetic disease. Tubules have occasional proteinaceous casts. About 5% of the cortex has interstitial fibrosis and tubular atrophy. Small arteries have moderate arteriosclerosis. Arterioles have focal hyalinosis. The permanent sections of this block have a similar appearance and were signed out separately (S16-6511). DONOR KIDNEY BIOPSY, LEFT (FROZEN SECTION): ARTERIOSCLEROSIS, SEE NOTE. NOTE: The 2 frozen sections of a wedge cortical biopsy stained with H&E show a total of about 63 glomeruli of which 3 are globally sclerotic (5%). The glomeruli show no evidence by light microscopy of diabetic disease. Tubules have occasional proteinaceous casts. About 5% of the cortex has interstitial fibrosis and tubular atrophy. Small arteries have moderate arteriosclerosis. Arterioles have focal hyalinosis. The permanent sections of this block have a similar appearance and were signed out separately (S16-6511).
9	DZI20-202-Case-9 DZI20-202-Case-9	donor bx	KIDNEY (DONOR), WEDGE BIOPSY (FROZEN SECTION): ACUTE TUBULAR INJURY, SEE NOTE. GLOBAL GLOMERULOSCLEROSIS (9%) INTERSTITIAL FIBROSIS AND TUBULAR ATROPHY (20%) MODERATE TO SEVERE ARTERIOSCLEROSIS MODERATE ARTERIOLAR HYALINOSIS Note: Histologic section shows a wedge of frozen cortical tissue with about 77 glomeruli, of which 7 are globally sclerotic. Two glomeruli show periglomerular fibrosis while a few glomeruli show segmental wrinkling and ischemic collapse. The remaining glomeruli appear generally unremarkable. Crescents, necrosis and thrombi are not identified. Tubular injury characterized by tubular dilatation and loss of brush borders is present. Interstitial inflammation is minimal. Fibrosis and tubular atrophy affect about 20% of the cortical area. Arteries show moderate intimal fibrosis. Arterioles show hyalinosis. Vasculitis and thrombi are not present. KIDNEY (DONOR), WEDGE BIOPSY (FROZEN SECTION): ACUTE TUBULAR INJURY, SEE NOTE. GLOBAL GLOMERULOSCLEROSIS (9%) INTERSTITIAL FIBROSIS AND TUBULAR ATROPHY (20%) MODERATE TO SEVERE ARTERIOSCLEROSIS MODERATE ARTERIOLAR HYALINOSIS Note: Histologic section shows a wedge of frozen cortical tissue with about 77 glomeruli, of which 7 are globally sclerotic. Two glomeruli show periglomerular fibrosis while a few glomeruli show segmental wrinkling and ischemic collapse. The remaining glomeruli appear generally unremarkable. Crescents, necrosis and thrombi are not identified. Tubular injury characterized by tubular dilatation and loss of brush borders is present. Interstitial inflammation is minimal. Fibrosis and tubular atrophy affect about 20% of the cortical area. Arteries show moderate intimal fibrosis. Arterioles show hyalinosis. Vasculitis and thrombi are not present.
10	DZI20-202-Case-10 DZI20-202-Case-10	donor bx	KIDNEY (DONOR), WEDGE BIOPSY: ACUTE TUBULAR INJURY, SEE NOTE. Note: Two slides with sections of a wedge of frozen cortical tissue contain a total of about 124 glomeruli, of which none is globally sclerotic. Glomeruli appear generally unremarkable, some with intracapillary neutrophils. Crescents, necrosis and thrombi are not present. There is subcapsular interstitial inflammation and focally in areas of fibrosis. Tubular atrophy and fibrosis are minimal ~5%. Tubules are dilated and show occasional protein casts and red cells. Arteries and arterioles are unremarkable. Vasculitis and thrombi are not present. KIDNEY (DONOR), WEDGE BIOPSY: ACUTE TUBULAR INJURY, SEE NOTE. Note: Two slides with sections of a wedge of frozen cortical tissue contain a total of about 124 glomeruli, of which none is globally sclerotic. Glomeruli appear generally unremarkable, some with intracapillary neutrophils. Crescents, necrosis and thrombi are not present. There is subcapsular interstitial inflammation and focally in areas of fibrosis. Tubular atrophy and fibrosis are minimal ~5%. Tubules are dilated and show occasional protein casts and red cells. Arteries and arterioles are unremarkable. Vasculitis and thrombi are not present.

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