RENAL BIOPSY and GLOMERULONEPHRITIS by J
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Postgrad Med J: first published as 10.1136/pgmj.35.409.604 on 1 November 1959. Downloaded from 604 RENAL BIOPSY AND GLOMERULONEPHRITIS By J. H. Ross, M.D., M.R.C.P. Senior Medical Registrar, The Connaught Hospital, and Assistant, The Mledical Unit, The London Hospital Introduction sufficient to establish a diagnosis in a few condi- Safe methods of percutaneous renal biopsy were tions such as amyloid disease and diabetic first described by Perez Ara (1950) and Iversen glomerulosclerosis, but cortex with at least io and Brun (I95I) who used aspiration techniques. glomeruli is necessary for an accurate assessment Many different methods have since been described; of the renal structure; occasionally, up to 40 the simplest is that of Kark and Muehrcke (1954) glomeruli may be present in a single specimen. who use the Franklin modification of the Vim- The revelation of gross structural changes in Silverman needle. the kidneys of patients who can be recognized Brun and Raaschou (1958) have recently re- clinically as having chronic glomerulonephritis is viewed the majority of publications concerned of little value and does not contribute to manage- with renal biopsy and have concluded that the risk ment or prognosis. In contrast, biopsy specimensProtected by copyright. to the patients is slight. They mentioned three from patients in the early stages of glomerulo- fatalities which have been reported but considered nephritis, particularly those who have developed that, in each case, death was probably due to the the nephrotic syndrome insidiously without disease process rather than the investigation. haematuria or renal failure or who showy no Retroperitoneal haematomata have been recorded evidence of disease other than proteinuria, may in patients with hypertension or uraemia but are provide useful information. The value of histo- unusual. Gross haematuria is uncommon (it oc- logical study in such cases is, however, limited by curred in 7.9 per cent. of 51o biopsy attempts by the interpretation of the significance of minor Brun and Raaschou, 1958, and 7 per cent. of ioo non-specific lesions. Insufficient time has passed biopsy attempts by Muehrcke, Kark and Pirani, since the introduction of renal biopsy to allow 1955). Pain in the loin following the procedure is many conclusions to be drawn as to the correlation also unusual. Although the procedure is simple, between such histological features and the sub- it should not be undertaken without careful sequent progress of the patients. instruction. The application of renal biopsy to the study of http://pmj.bmj.com/ The contraindications observed by those ex- glomerulonephritis will be discussed in this article; perienced in renal biopsy have varied considerably. many references to its use in other renal diseases A haemorrhagic diathesis is, of course, an absolute may be found in the review by Bnm and contraindication. Patients with hydronephrosis, Raaschou (1958). pyonephrosis, renal tuberculosis or neoplasm, very small kidneys, only one kidney or who are The Nephrotic Syndrome (Type U Nephritis) unable to cooperate, should not be submitted to Variations in and criteria, terminology diagnostic on September 28, 2021 by guest. the procedure. Most authors have considered as with so much of the literature of renal disease, uraemia a contraindication because of the asso- have made it difficult to compare the results of ciated haemorrhagic tendency, but Brun and different workers, especially when full case reports Raaschou (I958) have not found any significant have not been presented. increase in the frequency of haematuria after The term ' nephrotic syndrome' was first in- biopsy in II9 uraemic patients and, in fact; con- troduced by Leiter in I931 to differentiate the sider acute uraemia of unknown aetiology to be an association of massive proteinuria, oedema, hypo- indication for the investigation. proteinaemia and hypercholesterolaemia with Tissue, adequate for histological examination, renal disease such as glomerulonephritis from can be obtained in about 75 per cent. of cases. The ' lipoid nephrosis ' which was considered to have specimen may be regarded as representative of the the same four features without hypertension, kidney except in focal diseases such as pyelo- nitrogen retention, an excess of red blood cells in nephritis. Very small fragments of tissue may be the urine or histological glomerular lesions. Postgrad Med J: first published as 10.1136/pgmj.35.409.604 on 1 November 1959. Downloaded from November 1959 ROSS: Renal Biopsy and Glomerulonephritis 605 lar lesions at present give the best indication of the subsequent progress which may be expected, but further study may reveal the significance of minor tubular and interstitial features. The finding of .......... generalized basement membrane thickening (Fig. i) or intercapillary hyalinization in the glomeruli probably indicates that recovery is impossible and that progress to renal failure with hypertension, even though it may be delayed for many years, is inevitable; the use of steroids for the treatment of patients with these lesions is usually disappointing. The recognition of small increases in basement membrane thickening is, however, difficult and, in ...;^°.',...l.... addition, Rich (957) has shown, in necropsy specimens, that the lesions may be more pro- nounced in the juxtamedullary zone than in the outer cortex; such considerations may cast doubt on the interpretation of some small specimens. The interpretation of minor focal lesions in the kidneys of these patients is even more difficult. Increase in tuft cells, basement membrane thickening, intercapillary hyalinization and capsu- lar adhesions are found diffusely or locally in occasional glomeruli but are not generalized Protected by copyright. (Bjornoboe et al., 1952; Kark et al., I955; Ross and Ross, 1957; Joekes et al., 1958). Recovery from the disease is still possible and the severity of the FIG. i -Glomerulus with diffuse basement membrane lesions may give some indication of the thickening. This feature was present in all of I5 subsequent progress of the patient; conclusions glomeruli in the specimen from a man aged 52 years beyond these are not yet possible. There has been with the nephrotic syndrome of seven months only one report of serial biopsies duration. Renal failure and hypertension have demonstrating developed. Heidenhain's Azan stain, x 310. that such minor lesions precede generalized base- ment membrane thickening (Joekes et al., 1958) but circumstantial evidence suggests that this may 'Nephrotic syndrome' is not a diagnosis in itself be a frequent structural sequence. It seems un- and should always be qualified by the associated likely that any small structural differences in these disease process or aetiological agent if these can be cases will be recognized by conventional micro- recognized clinically or histologically (Kark et al., scopy which will allow the histologist to foretell http://pmj.bmj.com/ 1958, listed 31 possible causes of the syndrome). recovery, a long benign course or progress to The condition, when no cause has been identified, renal failure. has been variously termed 'type II nephritis,' Some biopsy specimens from these patients 'lipoid nephrosis,' the 'uncomplicated' or 'idio'- show no glomerular lesions at all; again, recovery pathic' nephrotic syndrome or has been given a may occur but cannot be foretold with certainty. histological label according to the school of thought Prolonged follow-up of a large number of patients of the observer. In this article, type II nephritis is necessary before more definite conclusions can on September 28, 2021 by guest. will be the name used whether the fully developed be reached. Electron microscope studies (Far- lesions described by Ellis in 1942 (the mem- quhar et al., I957 a, b and c; Folli et al., 1958; branous or lobular glomerulonephritis of Allen, Brun and Raaschou, I958) have shown that an I95I and 1955) are shown to be present or not. abnormality of the glomerular epithelial cells may Amyloid disease may occasionally be revealed be found in biopsy specimens from patients with unexpectedly by biopsy in patients considered early type II nephritis (the authors used different clinically to have early type II nephritis (Bjornoboe nomenclature) even when conventional micro- et al., I952; Ross and Ross, 1957). This finding scopy has revealed no abnormalities. The charac- suggests a worse prognosis and may prevent teristic 'foot processes' of normal epithelial cells valueless treatment with steroids. (podocytes) disappear and the epithelial cytoplasm Patients with early type Ir nephritis, whose becomes closely applied to the basement mem- clinical features are similar, may be found to have branes of the capillary loops. This change has not strikingly different histological lesions. Glomeru- been noted in acute nephritis but it is still not clear Postgrad Med J: first published as 10.1136/pgmj.35.409.604 on 1 November 1959. Downloaded from 6o6 POSTGRADUATE MEDICAL JOURNAL November 1959 w.b 44 sI4 .......... Ot:4V p4.4 Protected by copyright. FIG. 3.-Case 2. Glomerulus with small areas of base- FIG. 2.-Case i. One of the most severely affected ment membrane thickening and intercapillary glomeruli in the specimen, showing intercapillary hyalinization adherent to Bowman's capsule. hyalinization and capsular adhesion. Periodic- Periodic-acid-Schiff stain, x 330. acid-Schiff stain, X 330. if its recognition can be used to differentiate a appeared after another four months and she has