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Non-specific histopathological changes in kidney with renal tubular dysgenesis
ARTICLE IN PRESS Pathology – Research and Practice 206 (2010) 14–18
Contents lists available at ScienceDirect
Pathology – Research and Practice journal homepage: www.elsevier.de/prp
Original Article
Non-specific histopathological changes in kidney with renal tubular dysgenesis Moisey Moldavsky Department of Pathology, Ziv Medical Center, Zefat, Israel
a r t i c l e in f o
a b s t r a c t
Article history: Received 27 January 2009 Received in revised form 8 June 2009 Accepted 17 June 2009
Absence of proximal convoluted tubules (APCT) is a specific pathomorphological change found in kidney with renal tubular dysgenesis (RTD). Non-specific structural abnormalities in the kidney with this disorder have rarely been reported. The aim of this study was to detect non-specific histopathological changes (NSHC) in RTD kidney, to evaluate their incidence, and to establish a possible relationship to various etiological-pathogenic variants of RTD. Kidneys of 12 patients with RTD diagnosed in 9 Israeli hospitals were studied. Paraffin sections were examined using histological, histochemical, and immunohistochemical stains as well as morphometry. APCT was found to be associated with microcalcifications (MC) (66.6%), medullary ray nodules (MRN) (16.6%), extramedullary hematopoiesis (EH) (16.6%), and multinuclear giant cell (MGC) reaction (8.3%). MC contained calcium oxalate (33.3%) and calcium phosphate (carbonate) (33.3%), and were predominantly formed prenatally. MRN were also formed before birth. Definitive differences regarding NSHC character and frequency were found in diverse etiological-pathogenic variants of RTD. APCT in kidney with RTD is not infrequently associated with histopathological changes, which have extremely rarely been reported in prenatal and early postnatal kidney. MRN and EH in an autosomal recessive (AR) variant of RTD are more frequent than in twin–twin transfusion (TTT) syndrome. & 2009 Elsevier GmbH. All rights reserved.
Keywords: Renal tubular dysgenesis Kidney histopathology
Introduction Absence or poor differentiation of proximal convoluted tubules (PCT) is a substrational manifestation of renal tubular dysgenesis (RTD). Another permanent, but non-specific, feature in RTD is interlobular and preglomerular arteries muscular wall thickening [15], as well as increased renin accumulation in preglomerular arterioles, glomerular hilums, and glomerular mesangial areas [6]. Marked hypotrophy of all nephron segments from the glomerulus to the connecting tubule [3] and microcalcifications [2,17] have also been described in a case report. Searching for RTD frequency in 9 Israeli hospitals, we found 12 cases with abnormalities [19]. Several rarely reported structural abnormalities of the kidney were detected, and their incidence, co-association, and presence in different etiological-pathogenic variants of RTD are described in the current study.
Materials and methods Paraffin sections of 12 kidneys with RTD were studied using standard histological, histochemical, and immunohistochemical E-mail address: [email protected] 0344-0338/$ - see front matter & 2009 Elsevier GmbH. All rights reserved. doi:10.1016/j.prp.2009.06.012
methods, including hematoxylin and eosin (H&E), periodic-acid Schiff (PAS), von Kossa, Prussian blue reaction (Pearl’s stain), Yasue silver rubeanic acid, immunostaining for EMA (monoclonal mouse antibody, Daco), lysozyme (Diagnostic Product Corp. [DPCs] Los Angeles, CA, USA), CD-15 (monoclonal mouse antibody, Daco), vimentin (monoclonal mouse antibody, Daco), and alpha smooth muscle actin (monoclonal mouse antibody, Dako). H&E-stained slides were examined under polarized light. Morphometry of medullary ray nodules (MRN) was done by ocular micrometer. A control group of 55 cases included 45 cases of stillborns and fetuses delivered by pregnancy termination at 21–40 weeks of gestation without oligohydramnios, and 10 cases of autopsied neonates without anuria from the first week of life who died from congenital malformations or birth trauma. H&E-stained sections were examined using a light and polarized microscope.
Results Twelve cases of RTD were detected in the search for RTD frequency in 9 Israeli hospitals. Seven of these 12 cases were found to be autosomal recessive; 4 were TTT-induced, and 1 presented as non-steroidal anti-inflammatory drug (NSAID)induced variant [19].
ARTICLE IN PRESS M. Moldavsky / Pathology – Research and Practice 206 (2010) 14–18
Table 1 presents the clinical data and non-specific histopathological findings in the kidney with renal tubular digenesis. Microcalcifications (MC) were found in 8 of 12 RTD (66.6%). Tinctorial and physical properties of MC permit their description as calcium oxalates or calcium phosphate (carbonate) [8,12,14,16]. Calcium oxalate MC are invisible in H&E-stained preparations and in von Kossa stain, but are positive in Yasue stain and birefrigent under polarized light. Calcium phosphate (carbonate) MC are basophilic in H&E preparations, von Kossa-positive, Yasue-negative, and mute in polarized light. MC in RTD may be divided into two groups according to tinctorial and physical properties. The first group includes 4 cases (33.3%), in which MC contained calcium phosphate (carbonate). MC were found within the lumen of cortical tubules (including tubules of MRN) in all cases, within the glomerular capsule in 2 cases, and in the interstitium in 1 case. In the medulla, the MC were situated within the tubular lumen in 2 cases, and in the interstitium in 2. In the neogenic zone, von Kossa-positive MC were present in 3 kidneys. Two kidneys contained singular psammoma bodies (Fig. 1). The interstitium in all 4 kidneys was increased. In one kidney, some calcium deposits were surrounded by mononuclear cells, hemosiderin-laden macrophages, and MGC, some with intracytoplasmic calcium particles (Fig. 2). In three other cases, MC did not induce inflammatory cellular reaction. RTD, in two cases with calcium phosphate (carbonate) MC, was autosomal recessive in origin, but TTT-induced in two other cases. In 4 kidneys (33%), MC contained calcium oxalate. Under polarized light, they appeared as intratubular rosette-shaped deposits (2 cases) (Fig. 3) or smooth ovoid crystals (4 cases) situated in the cortex (2 cases), the medulla (1 case), or the neogenic zone (1 case). The interstitium of the kidney with MC containing calcium oxalate was increased. Basophilic (H&E)stained singular psammoma body was found in 1 of 4 cases. Oxalate deposits were found in 3 cases of autosomal recessive and in 1 case of NSAID variants of RTD kidneys. Two of 55 control kidneys showed the presence of H&E and von Kossa-positive MC, i.e., they contained calcium phosphate (carbonate). MRN were found in RTD kidneys of 2 babies (16.6%) with autosomal recessive RTD, who died within the first 25 hours of life. Nodules were situated predominantly in the mid third cortex. The nodules were oval in shape, elongated, and radially oriented. They contained tubules and were rich in stroma (Fig. 4). The longest to shortest diameter ratio was 6.04:1 and 6.00:1. The surface area of MRN ranged from 16565.8 to 236553.6 m2. They
15
were partially circumscribed by vimentin-positive fibers. Each nodule contained several (up to 15) EMA-positive and lysozymenegative tubules, separated and entrapped by irregular septa of vimentin-positive and actin-negative fibrillar stroma.
Fig. 1. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. Case 2. AR variant of RTD. Intratubular psammoma body. HE. 400.
Fig. 2. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. Case 10. TTT variant of RTD. Multinuclear giant cells with intracytoplasmic calcium phosphate (carbonate) deposits. von Kossa. 400.
Table 1 Clinical data and nonspecific histopathological findings in kidney with renal tubular dysgenesis. Case number
RTD variant
Age of gestation (wks)
Life span
Body weight (g)
Intensive therapy
Calcium oxalate
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12
TTT AR TTT NSAID TTT AR AR AR AR TTT AR AR
28 29 20 23 27 25 35 37 31 30 35 35
49 h 35 h SB TOP 0.5 h TOP 7h 1.5 h SB 1h 90 h 25 h
650 1350 336 230 585 750 2715 2180 ND 850 2080 2200
+ +
+
Calcium phosphate
Psammoma body
MGC MRN EH HLM
+
+ + + +
+ +
+ +
+ + + +
+ +
+
+
+ +
+
Abbreviations: AR- autosomal recessive; TTT- twin–twin transfusion; NSAID- non-steroidal anti-inflammatory drug; SB- stillbirth; TOP- termination of pregnancy; MGCmultinuclear giant cells; MRN- medullary ray nodules; EH- extramedullary hematopoiesis; HLM-hemosiderin-laden macrophages; ND- not data.
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Fig. 3. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. Case 7. AR variant of RTD. Intratubular rosette-shaped birefrigent microliths of calcium oxalate. HE. Semi-polarized light. 400.
Fig. 5. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. Case 12. AR variant of RTD. Two megakaryocytes in renal medulla. HE. 600.
Fig. 6. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. Case 10. TTT variant of RTD. Hemosiderinladen macrophages in renal interstitium. Prussian blue reaction. 100.
No MRN were found in 55 control kidneys. In 2 cases (16.6%), focal aggregates of mononuclear cells were found with a megakaryocytic (Fig. 5) admixture (1 case) and diffuse mononuclear infiltration (1 case). Mononuclear cells in focal and diffuse infiltrates were CD 15-immunopositive. In one case (8.4% ), hemosiderin-laden macrophages in renal interstitium (Fig. 6) were situated in definitive cortex adjacent to MGC with intracytoplasmic deposits of calcium phosphate (carbonate), but no other blood rests. No mononuclear aggregates, megakaryocytes, or hemosiderinladen macrophages were found in 55 control kidneys. Absence of proximal convoluted tubules (APCT), as a morphological substrate of kidney with RTD, may associate with 2 or more pathomorphological structures. APCT and MRN were found to be associated with oxalate deposits (1 case) and CD15-positive mononuclear cell infiltration (2 cases, 1 with megakaryocytes admixture). APCT, MC containing phosphate (carbonate), and MGC with intracytoplasmic deposits of calcium phosphate (carbonate) were associated with hemosiderin-laden macrophages (1 case).
Discussion Fig. 4. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. MRN in the kidney midcortex. HE. (a) Case 7. AR variant of RTD. 30; (b) Case 12. AR variant of RTD. 200.
Non-specific histopathological changes (NSHC) in kidney with RTD have rarely been described, and their histopathology, frequency, and mechanisms of formation are poorly understood.
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Reports of MC in fetal and neonatal kidneys are particularly rare [16,23]. According to clinical ultrasound examinations, the incidence of MC in neonates ranges from 8 to 93%. Corresponding to pathomorphological analyses, the incidence of nephrocalcinosis among 7 to 639-day-old infants is 18.18%[16] and 3.6% in our control group. Low birth weight and furosemide therapy are predisposing factors [1]. In the present study, the body weight of 5 babies with RTD associated with MC was less than 1500 g. A search of the literature uncovered only 3 cases of kidney MC [2,17], reported among 109 (2.75%) published RTD cases [19]. Deposits were seen in H&E preparations, suggesting their phosphate (carbonate) composition. Our study revealed a high incidence of MC in RTD (66.6%) when compared to the literature (RTD: 2.75%, non-RTD: 18.18%) and our control group (3.6%). Four RTD patients with calcium phosphate (carbonate) deposits survived less than 1.5 h and did not undergo furosemide treatment. Singular psammoma bodies were present in kidneys in 2 of them. The presence of psammoma bodies at the time of birth together with the absence of intensive therapy is evidence of prenatal calcium phosphate (carbonate) deposits and psammoma body formation in the course of RTD. MGC with intracytoplasmic deposits of calcium phosphate (carbonate) were also prenatally formed in RTD. Giant cell formation is known to be a reaction of kidney interstitium to calcium deposits [9]. The ability of multinuclear giant cells to dissolve calcium deposits was found to be true for different organs and tissue, including the kidney [9]. Some giant cells may contain intracytoplasmic calcium microliths [27]. Thus, the absence of proximal convoluted tubules in RTD kidney is associated with prenatal development of calcium oxalate, calcium phosphate (carbonate) deposits with giant cell reaction, and psammoma body formation. MC in 4 (33.3%) RTD cases were composed of calcium oxalate, whereas 4 others (33.3%) contained calcium phosphate (carbonate). In intensively treated infants, MC contained calcium oxalate and calcium phosphate in a considerably lower proportion (18.18% and 4.5%, respectively) [16]. Intensive treatment as a cause of oxalate formation may be suggested in 2 RTD patients (16.6%). However, the formation of deposits during prenatal life in such cases cannot be ruled out. Undoubtedly, oxalate deposits were prenatally formed in 2 fetuses (16.6%) delivered by pregnancy termination. Another cause of oxalate crystal deposits in RTD may be linked to the absence of calgranulin and uropontin (osteopontin) action. It is known that calgranulin [10,22] and uropontin (osteopontin) [11] are secreted by proximal epithelium cells, and that both inhibit calcium oxalate crystallization [4,22]. The absence of or decrease in proximal convoluted tubules in RTD removes or inhibits calgranulin and uropontin (osteopontin) effects and may facilitate calcium oxalate crystallization. The interstitium of kidney with MC was found to be increased. It was also increased in 4 of our cases, as well as in 32 published RTD cases in which the kidney lacked MC. Previously described MRN have been reported as most common between 1 and 6 months of age [5,7,25]. In RTD kidney, MRN were found in 2 neonates (16.6%) who survived 7 and 25 h after birth, which is evidence that MRN formed prenatally. The immunophenotype of tubules confirms the absence of proximal convoluted tubules (PCT) in RTD kidney cortex and MRN. PCT were present in MRN in the kidney, where this part of nephron existed outside nodules as well [18]. Thus, the absence of PCT within MRN is characteristic of RTD. Pathological conditions where MRN were detected include RTD, polycystic changes[18], and triphasic Wilms’ tumor associated with nephrogenic rest and ‘‘Beckwith medulla’’ in a 15-month-old infant [26].
17
Mononuclear cells in focal and diffuse renal infiltrates were CD-15-immunopositive. This staining detects lymphoid cells, promyelocytes, and monocytes [21]. The presence of megakaryocytes completes lympho- and myelopoiesis in RTD kidney as a EH process. The incidence of EH in RTD kidneys in our series was 16.6% (2 cases). A search of 109 publications [19] with comprehensive descriptions of the clinical and pathological findings detected 1 case (0.92%) of EH in RTD kidney [24]. All 3 cases were of autosomal recessive origin. RTD enlarges the list of congenital renal malformations [13,20] accompanied by EH in kidney. RTD has been reported as an autosomal recessive disorder [2]. Clinical manifestations and kidney morphological changes identical to RTD have been described in the kidney of donors with twin–twin transfusion (TTT) syndrome, fetuses exposed to angiotensin- converting enzyme inhibitors (ACEI), and nonsteroidal anti-inflammatory drug (NSAID) [15,19]. The current study permits evaluation of the presence of previously unreported various non-specific changes in different etiological-pathogenic variants of RTD. The frequency of MC in autosomal recessive RTD is 71.4% (5 cases); deposits contained calcium oxalate and calcium phosphate (carbonate), and in 2 of them, psammoma bodies were present. MRN and EH were found in autosomal recessive RTD only at a similar frequency (28.5%). The frequency of MC in a TTTinduced variant of RTD is 50% (2 cases). Deposits contained calcium phosphate (carbonate), and in 1 of them, they appeared as psammoma bodies. MC in NSAID-induced RTD (1 case) (14.3%) contained calcium oxalate.
Conclusions Non-specific histopathological changes in RTD have been rarely and insufficiently described. In our study, NSHC were found to be not uncommonly associated with diagnostic RTD featureAPCT. In most RTD cases, they occur prenatally. MC, MRN, EH, and MGC may combine in RTD. We found an increased incidence of non-specific changes in autosomal recessive variants among other variants of RTD in our small series, with a limited case number of this very rare kidney malformation. Further studies may define these findings more concretely. References [1] N.D. Adams, J.C. Rowe, Nephrocalcinosis, Clin. Perinatology 19 (1992) 179–195. [2] J.E. Allanson, J.T. Pantzar, P.M. MacLeod, Possible new autosomal recessive syndrome with unusual renal histopathological changes, Am. J. Med. Genet. 16 (1983) 57–60. [3] I. Ariel, T.R. Wells, B.H. Landing, M. Sagi, B. Bar-Oz, N. Ron, E. Rosenmann, Familial renal tubular dysgenesis: a disorder not isolated to proximal convoluted tubules, Pediatr. Pathol. Lab. Med. 15 (1995) 915–922. [4] J.R. Asplin, D. Arsenault, J.H. Parks, F.L. Coe, J.R. Hoyer, Contribution of human uropontin to inhibition of calcium oxalate crystallization, Kidney Int. 53 (1998) 194–199. [5] D.R. Benjamin, J.B. Beckwith, Medullary ray nodules in infancy and childhood, Arch. Pathol. 96 (1973) 33–35. [6] J. Bernstein, L. Barajas, Renal tubular dysgenesis: evidence of abnormality in the renin–angiotensin system, J. Am. Soc. Nephrol. 45 (1994) 224–227. [7] J.B. Beckwith, Pediatric kidney, in: S.S. Sternberg (Ed.), Histology for Pathologists, second ed., Lippincott-Raven, 1997, p. 793. [8] A.J. Chaplin, Histopathological occurrence and characterization of calcium oxalate: a review, J. Clin. Pathol. 30 (1977) 800–811. [9] R. de Water, C. Noordermeer, T.H. van der Kwast, H. Nizze, E.R. Boeve , D.J. Kok, ¨ F.H. Schroder, Calcium oxalate nephrolithiasis: effect of renal crystal deposition on the cellular composition of the renal interstitium, Am. J. Kidney Dis. 33 (1999) 761–771. [10] L.G. Fine, R.W. Holley, H. Nasri, B. Badie-Dezfooly, BSC-1 growth inhibitor transforms a mitogenic stimulus into a hypertrophic stimulus for renal proximal tubular cells: Relationship to Na+/H+ antiport activity, Proc. Natl. Acad. Sci. USA 82 (1985) 6163–6166. [11] K.L. Hudkins, C.M. Giachelli, Y. Cui, W.G. Couser, R.J. Johnson, C.E. Alpers, Osteopontin expression in fetal and mature human kidney, J. Am. Soc. Nephrol. 10 (1999) 444–457. [12] IHCWorld /http://www.ihcworld.com/_protocols/special_stains/von_kossa.htmS.
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[13] N. Kakkar, S. Menon, B.D. Radorta, Histomorphology of renal dysplasia – an autopsy study, Fetal Pediatr. Pathol. 25 (2006) 73–86. [14] R.D. Lillie, Histopathological Technique and Practical Histochemistry, third ed., McGraw-Hill book company, New York–Toronto–Sydney–London, 1965 (Russian trans by V.V.Portugalov, Moscow, p. 407). [15] D. Mahieu-Caputo, M. Dommergues, A.-L. Delezoide, M. Lacoste, Yi Gai, F. Narcy, D. Jolly, M. Gonzales, Y. Dumez, M.-C. Gubler, Twin-to-twin transfusion syndrome. Role of the fetal renin–angiotensin system, Am. J. Pathol. 156 (2000) 629–636. [16] F.C.S. McCormick, K. Brady, C.E. Keen, Oxalate nephrocalcinosis: a study in autopsied infants and neonates, Pediatr. Pathol. Lab. Med. 16 (1996) 479–488. [17] J.M. Milunsky, D.R. Genest, A. Milunsky, Renal tubular dysgenesis with microcephaly, Pediatr. Nephrol. 11 (1997) 494–496. [18] D. Miranda, R.A. Schinella, M.J. Finegold, Nodular dysgenesis in renal tubules. An early stage of pathogenesis of polycystic kidneys?, Arch. Pathol. 92 (1971) 377–383. [19] M. Moldavsky, Renal tubular dysgenesis in Israel: pathologist’s experience and literature review, Isr. Med. Assoc. J. 11 (2009) 6–10.
[20] I. Okayasu, A. Kajita, Histopathological study of congenital cystic kidneys with special reference to the multicystic, dysplastic type, Acta Pathol. Japan 28 (1978) 427–434. [21] Pathology Outline /http://pathologyoutlines.com/cdmarkers.htmlS. [22] S.N. Pillay, J.R. Asplin, F.L. Coe, Evidence that calgranulin is produced by kidney cells and is an inhibitor of calcium oxalate crystallization, Am. J. Physiol. Renal Physiol. 275 (1998) F255–F261. [23] J.J. Regalado, M.M. Rodriguez, J.B. Beckwith, Multinodular hyperplastic pannephric nephroblastomatosis with tubular differentiation: a new morphologic variant, Pediatr. Pathol. Lab. Med. 16 (1996) 961–972. [24] B.R. Schwartz, J.M. Lage, B.R. Pober, S.G. Driscoll, Isolated congenital renal tubular immaturity in siblings, Hum. Pathol. 17 (1986) 1259–1263. [25] N.M. Smith, M.J. Evans, V. Smith, A. Kelsey, Medullary ray nodule of the kidney, Pediatr. Dev. Pathol. 1 (1998) 70–73. [26] S. Rais-Bahrami, P. Argani, Unusual renal pathology associated with a Wilms’ tumor in a 15-month-old infant, Int. J. Surg. Pathol. 14 (3) (2006) 218–220. [27] A. Trantafyllou, J.D. Harrison, J.R. Garret, Microliths in normal salivary glands of cat investigated by light and electron microscopy, Cell Tissue Res. 272 (2) (1993) 321–327.
Contents lists available at ScienceDirect
Pathology – Research and Practice journal homepage: www.elsevier.de/prp
Original Article
Non-specific histopathological changes in kidney with renal tubular dysgenesis Moisey Moldavsky Department of Pathology, Ziv Medical Center, Zefat, Israel
a r t i c l e in f o
a b s t r a c t
Article history: Received 27 January 2009 Received in revised form 8 June 2009 Accepted 17 June 2009
Absence of proximal convoluted tubules (APCT) is a specific pathomorphological change found in kidney with renal tubular dysgenesis (RTD). Non-specific structural abnormalities in the kidney with this disorder have rarely been reported. The aim of this study was to detect non-specific histopathological changes (NSHC) in RTD kidney, to evaluate their incidence, and to establish a possible relationship to various etiological-pathogenic variants of RTD. Kidneys of 12 patients with RTD diagnosed in 9 Israeli hospitals were studied. Paraffin sections were examined using histological, histochemical, and immunohistochemical stains as well as morphometry. APCT was found to be associated with microcalcifications (MC) (66.6%), medullary ray nodules (MRN) (16.6%), extramedullary hematopoiesis (EH) (16.6%), and multinuclear giant cell (MGC) reaction (8.3%). MC contained calcium oxalate (33.3%) and calcium phosphate (carbonate) (33.3%), and were predominantly formed prenatally. MRN were also formed before birth. Definitive differences regarding NSHC character and frequency were found in diverse etiological-pathogenic variants of RTD. APCT in kidney with RTD is not infrequently associated with histopathological changes, which have extremely rarely been reported in prenatal and early postnatal kidney. MRN and EH in an autosomal recessive (AR) variant of RTD are more frequent than in twin–twin transfusion (TTT) syndrome. & 2009 Elsevier GmbH. All rights reserved.
Keywords: Renal tubular dysgenesis Kidney histopathology
Introduction Absence or poor differentiation of proximal convoluted tubules (PCT) is a substrational manifestation of renal tubular dysgenesis (RTD). Another permanent, but non-specific, feature in RTD is interlobular and preglomerular arteries muscular wall thickening [15], as well as increased renin accumulation in preglomerular arterioles, glomerular hilums, and glomerular mesangial areas [6]. Marked hypotrophy of all nephron segments from the glomerulus to the connecting tubule [3] and microcalcifications [2,17] have also been described in a case report. Searching for RTD frequency in 9 Israeli hospitals, we found 12 cases with abnormalities [19]. Several rarely reported structural abnormalities of the kidney were detected, and their incidence, co-association, and presence in different etiological-pathogenic variants of RTD are described in the current study.
Materials and methods Paraffin sections of 12 kidneys with RTD were studied using standard histological, histochemical, and immunohistochemical E-mail address: [email protected] 0344-0338/$ - see front matter & 2009 Elsevier GmbH. All rights reserved. doi:10.1016/j.prp.2009.06.012
methods, including hematoxylin and eosin (H&E), periodic-acid Schiff (PAS), von Kossa, Prussian blue reaction (Pearl’s stain), Yasue silver rubeanic acid, immunostaining for EMA (monoclonal mouse antibody, Daco), lysozyme (Diagnostic Product Corp. [DPCs] Los Angeles, CA, USA), CD-15 (monoclonal mouse antibody, Daco), vimentin (monoclonal mouse antibody, Daco), and alpha smooth muscle actin (monoclonal mouse antibody, Dako). H&E-stained slides were examined under polarized light. Morphometry of medullary ray nodules (MRN) was done by ocular micrometer. A control group of 55 cases included 45 cases of stillborns and fetuses delivered by pregnancy termination at 21–40 weeks of gestation without oligohydramnios, and 10 cases of autopsied neonates without anuria from the first week of life who died from congenital malformations or birth trauma. H&E-stained sections were examined using a light and polarized microscope.
Results Twelve cases of RTD were detected in the search for RTD frequency in 9 Israeli hospitals. Seven of these 12 cases were found to be autosomal recessive; 4 were TTT-induced, and 1 presented as non-steroidal anti-inflammatory drug (NSAID)induced variant [19].
ARTICLE IN PRESS M. Moldavsky / Pathology – Research and Practice 206 (2010) 14–18
Table 1 presents the clinical data and non-specific histopathological findings in the kidney with renal tubular digenesis. Microcalcifications (MC) were found in 8 of 12 RTD (66.6%). Tinctorial and physical properties of MC permit their description as calcium oxalates or calcium phosphate (carbonate) [8,12,14,16]. Calcium oxalate MC are invisible in H&E-stained preparations and in von Kossa stain, but are positive in Yasue stain and birefrigent under polarized light. Calcium phosphate (carbonate) MC are basophilic in H&E preparations, von Kossa-positive, Yasue-negative, and mute in polarized light. MC in RTD may be divided into two groups according to tinctorial and physical properties. The first group includes 4 cases (33.3%), in which MC contained calcium phosphate (carbonate). MC were found within the lumen of cortical tubules (including tubules of MRN) in all cases, within the glomerular capsule in 2 cases, and in the interstitium in 1 case. In the medulla, the MC were situated within the tubular lumen in 2 cases, and in the interstitium in 2. In the neogenic zone, von Kossa-positive MC were present in 3 kidneys. Two kidneys contained singular psammoma bodies (Fig. 1). The interstitium in all 4 kidneys was increased. In one kidney, some calcium deposits were surrounded by mononuclear cells, hemosiderin-laden macrophages, and MGC, some with intracytoplasmic calcium particles (Fig. 2). In three other cases, MC did not induce inflammatory cellular reaction. RTD, in two cases with calcium phosphate (carbonate) MC, was autosomal recessive in origin, but TTT-induced in two other cases. In 4 kidneys (33%), MC contained calcium oxalate. Under polarized light, they appeared as intratubular rosette-shaped deposits (2 cases) (Fig. 3) or smooth ovoid crystals (4 cases) situated in the cortex (2 cases), the medulla (1 case), or the neogenic zone (1 case). The interstitium of the kidney with MC containing calcium oxalate was increased. Basophilic (H&E)stained singular psammoma body was found in 1 of 4 cases. Oxalate deposits were found in 3 cases of autosomal recessive and in 1 case of NSAID variants of RTD kidneys. Two of 55 control kidneys showed the presence of H&E and von Kossa-positive MC, i.e., they contained calcium phosphate (carbonate). MRN were found in RTD kidneys of 2 babies (16.6%) with autosomal recessive RTD, who died within the first 25 hours of life. Nodules were situated predominantly in the mid third cortex. The nodules were oval in shape, elongated, and radially oriented. They contained tubules and were rich in stroma (Fig. 4). The longest to shortest diameter ratio was 6.04:1 and 6.00:1. The surface area of MRN ranged from 16565.8 to 236553.6 m2. They
15
were partially circumscribed by vimentin-positive fibers. Each nodule contained several (up to 15) EMA-positive and lysozymenegative tubules, separated and entrapped by irregular septa of vimentin-positive and actin-negative fibrillar stroma.
Fig. 1. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. Case 2. AR variant of RTD. Intratubular psammoma body. HE. 400.
Fig. 2. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. Case 10. TTT variant of RTD. Multinuclear giant cells with intracytoplasmic calcium phosphate (carbonate) deposits. von Kossa. 400.
Table 1 Clinical data and nonspecific histopathological findings in kidney with renal tubular dysgenesis. Case number
RTD variant
Age of gestation (wks)
Life span
Body weight (g)
Intensive therapy
Calcium oxalate
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12
TTT AR TTT NSAID TTT AR AR AR AR TTT AR AR
28 29 20 23 27 25 35 37 31 30 35 35
49 h 35 h SB TOP 0.5 h TOP 7h 1.5 h SB 1h 90 h 25 h
650 1350 336 230 585 750 2715 2180 ND 850 2080 2200
+ +
+
Calcium phosphate
Psammoma body
MGC MRN EH HLM
+
+ + + +
+ +
+ +
+ + + +
+ +
+
+
+ +
+
Abbreviations: AR- autosomal recessive; TTT- twin–twin transfusion; NSAID- non-steroidal anti-inflammatory drug; SB- stillbirth; TOP- termination of pregnancy; MGCmultinuclear giant cells; MRN- medullary ray nodules; EH- extramedullary hematopoiesis; HLM-hemosiderin-laden macrophages; ND- not data.
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Fig. 3. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. Case 7. AR variant of RTD. Intratubular rosette-shaped birefrigent microliths of calcium oxalate. HE. Semi-polarized light. 400.
Fig. 5. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. Case 12. AR variant of RTD. Two megakaryocytes in renal medulla. HE. 600.
Fig. 6. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. Case 10. TTT variant of RTD. Hemosiderinladen macrophages in renal interstitium. Prussian blue reaction. 100.
No MRN were found in 55 control kidneys. In 2 cases (16.6%), focal aggregates of mononuclear cells were found with a megakaryocytic (Fig. 5) admixture (1 case) and diffuse mononuclear infiltration (1 case). Mononuclear cells in focal and diffuse infiltrates were CD 15-immunopositive. In one case (8.4% ), hemosiderin-laden macrophages in renal interstitium (Fig. 6) were situated in definitive cortex adjacent to MGC with intracytoplasmic deposits of calcium phosphate (carbonate), but no other blood rests. No mononuclear aggregates, megakaryocytes, or hemosiderinladen macrophages were found in 55 control kidneys. Absence of proximal convoluted tubules (APCT), as a morphological substrate of kidney with RTD, may associate with 2 or more pathomorphological structures. APCT and MRN were found to be associated with oxalate deposits (1 case) and CD15-positive mononuclear cell infiltration (2 cases, 1 with megakaryocytes admixture). APCT, MC containing phosphate (carbonate), and MGC with intracytoplasmic deposits of calcium phosphate (carbonate) were associated with hemosiderin-laden macrophages (1 case).
Discussion Fig. 4. Non-specific histopathological changes following the absence of proximal convoluted tubules in the kidney with RTD. MRN in the kidney midcortex. HE. (a) Case 7. AR variant of RTD. 30; (b) Case 12. AR variant of RTD. 200.
Non-specific histopathological changes (NSHC) in kidney with RTD have rarely been described, and their histopathology, frequency, and mechanisms of formation are poorly understood.
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Reports of MC in fetal and neonatal kidneys are particularly rare [16,23]. According to clinical ultrasound examinations, the incidence of MC in neonates ranges from 8 to 93%. Corresponding to pathomorphological analyses, the incidence of nephrocalcinosis among 7 to 639-day-old infants is 18.18%[16] and 3.6% in our control group. Low birth weight and furosemide therapy are predisposing factors [1]. In the present study, the body weight of 5 babies with RTD associated with MC was less than 1500 g. A search of the literature uncovered only 3 cases of kidney MC [2,17], reported among 109 (2.75%) published RTD cases [19]. Deposits were seen in H&E preparations, suggesting their phosphate (carbonate) composition. Our study revealed a high incidence of MC in RTD (66.6%) when compared to the literature (RTD: 2.75%, non-RTD: 18.18%) and our control group (3.6%). Four RTD patients with calcium phosphate (carbonate) deposits survived less than 1.5 h and did not undergo furosemide treatment. Singular psammoma bodies were present in kidneys in 2 of them. The presence of psammoma bodies at the time of birth together with the absence of intensive therapy is evidence of prenatal calcium phosphate (carbonate) deposits and psammoma body formation in the course of RTD. MGC with intracytoplasmic deposits of calcium phosphate (carbonate) were also prenatally formed in RTD. Giant cell formation is known to be a reaction of kidney interstitium to calcium deposits [9]. The ability of multinuclear giant cells to dissolve calcium deposits was found to be true for different organs and tissue, including the kidney [9]. Some giant cells may contain intracytoplasmic calcium microliths [27]. Thus, the absence of proximal convoluted tubules in RTD kidney is associated with prenatal development of calcium oxalate, calcium phosphate (carbonate) deposits with giant cell reaction, and psammoma body formation. MC in 4 (33.3%) RTD cases were composed of calcium oxalate, whereas 4 others (33.3%) contained calcium phosphate (carbonate). In intensively treated infants, MC contained calcium oxalate and calcium phosphate in a considerably lower proportion (18.18% and 4.5%, respectively) [16]. Intensive treatment as a cause of oxalate formation may be suggested in 2 RTD patients (16.6%). However, the formation of deposits during prenatal life in such cases cannot be ruled out. Undoubtedly, oxalate deposits were prenatally formed in 2 fetuses (16.6%) delivered by pregnancy termination. Another cause of oxalate crystal deposits in RTD may be linked to the absence of calgranulin and uropontin (osteopontin) action. It is known that calgranulin [10,22] and uropontin (osteopontin) [11] are secreted by proximal epithelium cells, and that both inhibit calcium oxalate crystallization [4,22]. The absence of or decrease in proximal convoluted tubules in RTD removes or inhibits calgranulin and uropontin (osteopontin) effects and may facilitate calcium oxalate crystallization. The interstitium of kidney with MC was found to be increased. It was also increased in 4 of our cases, as well as in 32 published RTD cases in which the kidney lacked MC. Previously described MRN have been reported as most common between 1 and 6 months of age [5,7,25]. In RTD kidney, MRN were found in 2 neonates (16.6%) who survived 7 and 25 h after birth, which is evidence that MRN formed prenatally. The immunophenotype of tubules confirms the absence of proximal convoluted tubules (PCT) in RTD kidney cortex and MRN. PCT were present in MRN in the kidney, where this part of nephron existed outside nodules as well [18]. Thus, the absence of PCT within MRN is characteristic of RTD. Pathological conditions where MRN were detected include RTD, polycystic changes[18], and triphasic Wilms’ tumor associated with nephrogenic rest and ‘‘Beckwith medulla’’ in a 15-month-old infant [26].
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Mononuclear cells in focal and diffuse renal infiltrates were CD-15-immunopositive. This staining detects lymphoid cells, promyelocytes, and monocytes [21]. The presence of megakaryocytes completes lympho- and myelopoiesis in RTD kidney as a EH process. The incidence of EH in RTD kidneys in our series was 16.6% (2 cases). A search of 109 publications [19] with comprehensive descriptions of the clinical and pathological findings detected 1 case (0.92%) of EH in RTD kidney [24]. All 3 cases were of autosomal recessive origin. RTD enlarges the list of congenital renal malformations [13,20] accompanied by EH in kidney. RTD has been reported as an autosomal recessive disorder [2]. Clinical manifestations and kidney morphological changes identical to RTD have been described in the kidney of donors with twin–twin transfusion (TTT) syndrome, fetuses exposed to angiotensin- converting enzyme inhibitors (ACEI), and nonsteroidal anti-inflammatory drug (NSAID) [15,19]. The current study permits evaluation of the presence of previously unreported various non-specific changes in different etiological-pathogenic variants of RTD. The frequency of MC in autosomal recessive RTD is 71.4% (5 cases); deposits contained calcium oxalate and calcium phosphate (carbonate), and in 2 of them, psammoma bodies were present. MRN and EH were found in autosomal recessive RTD only at a similar frequency (28.5%). The frequency of MC in a TTTinduced variant of RTD is 50% (2 cases). Deposits contained calcium phosphate (carbonate), and in 1 of them, they appeared as psammoma bodies. MC in NSAID-induced RTD (1 case) (14.3%) contained calcium oxalate.
Conclusions Non-specific histopathological changes in RTD have been rarely and insufficiently described. In our study, NSHC were found to be not uncommonly associated with diagnostic RTD featureAPCT. In most RTD cases, they occur prenatally. MC, MRN, EH, and MGC may combine in RTD. We found an increased incidence of non-specific changes in autosomal recessive variants among other variants of RTD in our small series, with a limited case number of this very rare kidney malformation. Further studies may define these findings more concretely. References [1] N.D. Adams, J.C. Rowe, Nephrocalcinosis, Clin. Perinatology 19 (1992) 179–195. [2] J.E. Allanson, J.T. Pantzar, P.M. MacLeod, Possible new autosomal recessive syndrome with unusual renal histopathological changes, Am. J. Med. Genet. 16 (1983) 57–60. [3] I. Ariel, T.R. Wells, B.H. Landing, M. Sagi, B. Bar-Oz, N. Ron, E. Rosenmann, Familial renal tubular dysgenesis: a disorder not isolated to proximal convoluted tubules, Pediatr. Pathol. Lab. Med. 15 (1995) 915–922. [4] J.R. Asplin, D. Arsenault, J.H. Parks, F.L. Coe, J.R. Hoyer, Contribution of human uropontin to inhibition of calcium oxalate crystallization, Kidney Int. 53 (1998) 194–199. [5] D.R. Benjamin, J.B. Beckwith, Medullary ray nodules in infancy and childhood, Arch. Pathol. 96 (1973) 33–35. [6] J. Bernstein, L. Barajas, Renal tubular dysgenesis: evidence of abnormality in the renin–angiotensin system, J. Am. Soc. Nephrol. 45 (1994) 224–227. [7] J.B. Beckwith, Pediatric kidney, in: S.S. Sternberg (Ed.), Histology for Pathologists, second ed., Lippincott-Raven, 1997, p. 793. [8] A.J. Chaplin, Histopathological occurrence and characterization of calcium oxalate: a review, J. Clin. Pathol. 30 (1977) 800–811. [9] R. de Water, C. Noordermeer, T.H. van der Kwast, H. Nizze, E.R. Boeve , D.J. Kok, ¨ F.H. Schroder, Calcium oxalate nephrolithiasis: effect of renal crystal deposition on the cellular composition of the renal interstitium, Am. J. Kidney Dis. 33 (1999) 761–771. [10] L.G. Fine, R.W. Holley, H. Nasri, B. Badie-Dezfooly, BSC-1 growth inhibitor transforms a mitogenic stimulus into a hypertrophic stimulus for renal proximal tubular cells: Relationship to Na+/H+ antiport activity, Proc. Natl. Acad. Sci. USA 82 (1985) 6163–6166. [11] K.L. Hudkins, C.M. Giachelli, Y. Cui, W.G. Couser, R.J. Johnson, C.E. Alpers, Osteopontin expression in fetal and mature human kidney, J. Am. Soc. Nephrol. 10 (1999) 444–457. [12] IHCWorld /http://www.ihcworld.com/_protocols/special_stains/von_kossa.htmS.
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