Monday, October 1, 2012

January 2010 - Kidney Biopsy Results

Here is my mother's eagerly anticipated kidney biopsy report, medical-speak and all, followed by some commentary by yours truly.

Patient: LJ
Age: 68
Date collected: 12-28-09

Specimen submitted: Kidney, biopsy


Amyloidosis (see Comment).
Interstitial Fibrosis, Moderate
Arteriosclerosis, Moderate

Comment: There is Lambda greater than Kappa staining but not significant enough to definitively state that this is AL Amyloidosis. The section stained for AA Amyloid is negative.

Clinical History:

This 68 year-old female has proteinuria.

Gross Description:
Received from Medical Center of Plano, Plano, TX, their number S09-5892, are two specimen bottles, one contains Formalin and the other Michel's fixative, labeled with the patient's name, LJ.

Received in Formalin are two pieces of tissue measuring 1.4 x 0.1 x 0.1 and 0.1 x 0.1 x 0.1 cm. Two ends are submitted for electron microscopy and the remainder of the tissue is submitted in its entirety for light microscopy.

Received in Michel's fixative are three pieces of tissue measuring 1.3 x 0.1 x 0.1 cm (bloody), 0.4 x 0.1 x 0.1 cm (bloody) and 0.3 x 0.1 x 0.1 cm. The specimen is submitted in its entirety for immunofluorescence microscopy.

Microscopic Description:

Sections of kidney show 28 glomeruli, none of which are globally sclerotic. There is diffuse replacement of the uretal architecture by expansive hyaline masses involving the mesangial region and extending into capillary loops. This is silver negative on Jones Silver stain. No hypercellularity is seen.

There is moderate tubular atrophy and dropout with interstitial fibrosis associated with mild chronic inflammation. The blood vessels show moderate intimal fibrosis. There is focal hyaline infiltration similar to the material seen in the glomeruli. Toluidine Blue stained sections show 12 glomeruli, one of which is globally sclerotic. There is diffuse toluidine blue positive material replacing the usual architecture in masses of mesangial expansion. Moderate interstitial fibrosis is seen. Congo Red and Thioflavin T stains for amyloid are positive.

Twenty-two glomeruli are available for examination, none of which are globally sclerotic. The sections are stained for IgG, IgM, IgA, C3, C4, C1q, Albumin, Fibrinogen, Kappa and Lambda light chains. Two plus amounts of Lambada (sic) light chain and one plus amounts of Kappa light chain are seen in a hazy pattern over all glomeruli. The remaining stains are essentially negative.

Two blocks and multiple Toluidine Blue stained sections are prepared. One glomerulus is examined ultrastructurally. Glomerular sections show marked mesangial matrix expansion by crossshatched fibrilla material having size characteristics of amyloid. Frequently this material extends out into the subendothelial space. Extensive effacement of foot processes is present. The capillary loops are of the usual thickness and do not contain electron dense deposits.

And then there are three black and white pictures of biopsy slides, I assume. The word "Amyloid" is in the middle of the three pictures, with a line going to each picture. There is a fourth picture with the caption "Normal glomerulus for Comparison." One of the biopsy photos is the closest match to the "normal" photo, and the biopsy photo has significantly more white spots than the normal one. I'm guessing the white stuff is the amyloid.

I think I only understand slightly more about this report than I understood back when I first looked at it in January of 2010. Later on I would learn more about Lambda and Kappa chains, and Congo Red staining. At the time, of course, we focused on "Diagnosis: Amyloidosis" and this very important sentence:

"There is Lambda greater than Kappa staining but not significant enough to definitively state that this is AL Amyloidosis."

So based on this report, they're saying she has amyloidosis but they can't definitively say it's AL Amyloidosis. So our journey begins as we try to determine what she really has, and what should we do about it.

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