CASE 205 (March 2023)

Clinical information

A 56-year-old woman is evaluated for progressive edema. The paraclinical tests show nephrotic syndrome, with arterial hypertension, microhematuria, and elevated serum creatinine (mixed: nephrotic-nephritic). As antecedent: alcoholic liver disease. No family history of kidney disease.

Paraclinical: Hb: 11.4 mg/dL, Hct: 33%, platelets 230,000 / microliter; normal leukogram. Serum Cr: 1.9 mg/dL, BUN: 34 mg/dL; proteinuria: 5.4 g/24 hours, albumin: 2.4 g/dL; urinalysis: erythrocytes 20/HPF, leukocytes: 5-7/HPF, granular and red blood cell casts. ANAs: negative; C3: 98, C4: 22, anti-DNA and ANCAs: negative. HIV and hepatotropic viruses: negative. ALT 82 U/L (normal 7-55), AST 77 U/L (8-48), alkaline phosphatase 160 U/L (40-129), total bilirubin 1.3 mg/dL (0.1-1.2), direct bilirubin: 0.7 mg/dL (<0.3).

Renal biopsy is done, look at the images.

Figure 1. H&E, X400. Segmental hypercellularity and thickening of capillary walls.

Figure 2. H&E, X400.

Figure 3. H&E, X400. Segmental sclerosing lesion.

Figure 4. Masson´s trichrome stain, X400. Segmental sclerosing lesions and possible small epithelial crescent in the lower part of the image.

Figure 5. Masson´s trichrome stain, X400.

Figure 6. Masson´s trichrome stain, X400. Podocyte hyperplasia or crescent (?).

Figure 7. Metenamina-silver stain, X400. Double contours. Crescent versus severe podocyte hyperplasia.

Figure 8. Metenamina-silver stain, X400. Membranoproliferative pattern and small crescent on top.

Figure 9. Metenamina-silver stain, X400. Double contours. Mitosis, possibly of a podocyte, at the top.

Figure 10. Immunofluorescence for IgA, X400. Mesangial and subendothelial positivity.

Figure 11. Immunofluorescence for IgM, X400. Mesangial and subendothelial positivity.

Figure 12. Immunofluorescence for C3, X400. Mesangial and subendothelial positivity.

Figure 13. Immunofluorescence for IgG, X400. Negative (or traces).

Figure 14. Electron microscopy, original magnification, X2.550. Note a double contour in the capillary on the bottom.

Figure 15. Electron microscopy, original magnification, X2.550. Note electron-dense subendothelial deposits and extensive podocyte damage.

Figure 16. Electron microscopy, original magnification, X2.550. Irregular, wavy, possibly double-contoured basement membrane with electron-dense deposits.

Figure 17. Electron microscopy, original magnification, X2.550. Note electron-dense subendothelial deposits.

Direct immunofluorescence for C1q: Negative; kappa y lambda: similar staining to IgA and IgM.

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