Renal biopsy pathology in a cohort of patients from southwest Sydney with clinically diagnosed systemic lupus erythematosus

Figures & data

Table 1 Classes of lupus nephritis

Lupus nephritis class	Essential morphological abnormalities
I	No light microscopic, IF or EM changes
IIA	Normal by light microscopy but has mesangial-positive IF changes and positive EM changes within the mesangium
IIB	Mesangial hypercellularity plus positive changes on IF and EM
III	Focal and segmental proliferative changes by light microscopy, positive IF and EM changes
IV	Diffuse proliferative glomerulonephritis with positive IF and EM
V	Features of a diffuse membranous glomerulonephritis
VI	Advanced sclerosing glomerulonephritis

Adapted from the WHO classification of 1974 as reported by Weening et al.⁴

Abbreviations: WHO, World Health Organization; IF, immunofluorescence microscopy; EM, electron microscopy.

Table 2 Clinical indications for renal biopsy

Indication for renal biopsy	Cases (%)
Non-nephrotic proteinuria	62
Nephrotic range proteinuria	23
Hematuria gross and microscopic	26
Increasing serum creatinine	19
Clinical SLE and no other history provided	82
No history provided at time of biopsy	21

Abbreviation: SLE, systematic lupus erythematosus.

Table 3 Distribution of cases within classes of lupus nephritis based on race

WHO class	A	C	IS	ME	P	M	SA
Class 1	1	1	0	0	0	0	0
Class II	5	2	1	3	0	2	0
Class III	4	3	1	1	0	I	I
Class IV	13	7	3	1	2	0	0
Class V	2	1	1	0	2	0	1
Class VI	0	0	0	0	0	0	0
Total	25	14	6	5	4	3	2

Abbreviations: WHO, World Health Organization; A, Asian; C, Caucasian IS, Indian subcontinental; ME, Middle Eastern; P, Pacific Islander; M, Mediterranean SA, South American.

Table 4 Patient clinical information based on final diagnosis

Class of lupus nephritis	Patients (%)	F:M ratio	Age (M)	Previous history of SLE	H	P	H and P	Nephrotic syndrome	Increasing creatinine	HT
I	2(3)	2:0	33	2/2	0/2	1/2	0/2	0/2	0/2	0/2
IIA	4(7)	2:2	44	3/4	2/4	3/4	2/4	2/4	1/4	0/4
MB	9(15)	8:1	38	8/9	3/9	6/9	3/9	0/9	0/9	1/9
III	11(19)	8:3	35	9/11	5/11	11/11	5/11	0/11	3/11	1/11
IV	26 (44)	21:5	31	22/26	5/26	14/26	4/26	8/26	7/26	1/26
V	7(12)	7:0	37	5/7	3/7	5/7	3/7	4/7	2/7	0/7
VI	0(0)	0:0	0	0/0	0/0	0/0	0/0	0/0	0/0	0/0
Total	59* (100)	4.4:1	35	49	18	40	17	14	13	3

Note:

* There were also two patients suspected of having SLE that were not diagnosed with lupus nephritis.

Abbreviations: F, female; M, male; (M), mean; SLE, systematic lupus erythematosus; H, hematuria; P, proteinuria; HT, hypertension.

Table 5 Case pathology findings for classes of lupus nephritis

Class of lupus nephritis	Patients	Bx	Immunoglobulin deposition	Complement deposition	Hypertensive changes	Inflammatory infiltrate	Casts	Active disease	Chronic disease
I	2	2	0/2	0/2	0/2	1/2	0/2	2/2	0/2
IIA	4	4	4/4	4/4	0/4	2/4	1/4	4/4	0/4
IIB	9	10	9/10α	9/10α	5/10	7/10	7/10	4/10	6/10
III	II	14	14/14	14/14	0/14	8/14	10/14	5/14	9/14
IV	26	34	32/34β	3I/34β	13/34	31/34	19/34	9/34	25/34
V	7	7	7/7	7/7	1/7	5/7	6/7	2/7	5/7
Total	59	71*	66	65	19	54	43	26	45

Notes:

α One case did not display any immunopositivity, possibly due to technical error;

β two cases did not have the entire IHC test antibody panel and two more cases did not have an IgG test;

* some patients had multiple biopsies performed over the timeframe of this study. Scores are shown as number of biopsies with positive findings/ number of biopsies in group.

Abbreviations: Bx, multiple biopsies; IHC, immunohistochemistry; IgG, immunoglobulin G.

Figure 1 Class I lupus nephritis. Mesangium and capillary loops appear normal in hematoxylin and eosin-stained section (A), Masson’s trichrome (B), periodic acid-Schiff (C) and methenamine silver (D). Transmission electron microscopy also shows no abnormality in the capillary loops (E) or mesangium (F).

Figure 2 Glomerular capillary loop with granular trace deposits (arrows) in the subendothelium of the capillary basement membrane in a case with Class I lupus nephritis.

Note: An endothelial cell and podocyte are also shown.
Abbreviations: EC, endothelial cell; P, podocyte.

Figure 3 Class MB lupus nephritis.

Note: Immunofluorescence microscopy showing a case with “full house” staining of all classes of immunoglobulin, complement, and fibrinogen.
Abbreviation: IgA, immunoglobulin A; IgG, immunoglobulin G; IgM, immunoglobulin M; KLC, kappa light chain; LLC, lambda light chain; C1q, complement 1q; C3c; complement 3c; Fib, fibrinogen.

Figure 4 Class II lupus nephritis showing mesangial hypercellularity (asterisks).

Note: No deposits or other glomerular changes are evident in hematoxylin and eosin sections.

Figure 5 Granular electron dense deposits in Class MB lupus nephritis. (A) in the mesangium (short arrows) and (B) in the capillary basement membrane loops (long arrows).

Figure 6 Class III lupus nephritis showing a case with typical spectrum and pattern of positive immunofluorescence staining.

Abbreviations: IgA, immunoglobulin A; IgG, immunoglobulin G; IgM, immunoglobulin M; KLC, kappa light chain; LLC, lambda light chain; C1q, complement Iq; C3c; complement 3c.

Figure 7 Electron microscopy showing (A) large fine granular deposits in the mesangial region (arrows), (B) prominent fine granular subendothelial deposits (arrows) and some intramembranous deposits (arrow heads) in a case of Class III lupus nephritis.

Figure 8 When tissue for immunofluorescence microscopy is not available, special histological stains and conventional immunohistochemical staining visualized with diaminobenzidine (DAB) can reveal glomerular deposits in Class III to Class VI. (A) Hematoxylin and eosin showing some crowding of nuclei in a segmental mesangial proliferative lesion; (B) Masson’s trichrome stain showing segmental mesangial proliferation and thickened capillary loops; (C) deposits of IgM (arrows); (D) deposits of IgG (arrows); (E) mesangial deposits of C3c (arrows); (F) deposits of C3c in capillary loops.

Abbreviations: DAB, diaminobenzidine; Ig, immunoglobulin; C3c, complement 3c.

Figure 9 Class IV lupus nephritis. (A) Mesangial hypercellularity (asterisk) and deposits (arrows) associated with the capillary loops seen in a hematoxylin and eosin-stained section. (B) Foci of necrosis (asterisk), capillary loop deposits (arrow), and vascular thrombi (arrow head) are also seen. (C) Fuchsinophilic deposits (arrows) appear clearer in a Masson’s trichrome-stained section. (D) Hematoxylin bodies (arrows) appearing as darkly stained nuclei that blend into the background.

Figure 10 Class V lupus nephritis. Histological special stains are useful for further delineating the extent of glomerular deposits. (A) H&E-stained section of a Class V case showing mesangial hypercellularity. (B) H&E-stained section from a Class V case showing heavy deposits in the mesangium and capillary loops (arrows). (C) Fuchsinophilic deposits (arrows) on capillary loops seen in a Masson’s trichrome-stained section. (D) Deposits (arrows) in a Masson’s trichrome-stained section. (E) Deposits (arrows) seen in a PAS-stained section. (F) Basement membrane “spikes” in capillary loop deposits (arrows) seen in a methenamine silver-stained section.

Abbreviations: H&E, hematoxylin and eosin; PAS, periodic acid-Schiff.

Figure 11 Class IV lupus nephritis.

Note: Immunofluorescence staining for IgG showing widespread coarse granular deposits in capillary loops.
Abbreviation: IgG, immunoglobulin G.

Figure 12 Class IV lupus nephritis large electron-dense granular deposits around capillary loops are seen in the subepithelial space (arrows in A), the intramembranous region of the basement membrane (arrows in B) and the subendothelial space (arrows in C).

WeeningJJD’AgatiYSchwartzMMThe classification of glomerulonephritis in systemic lupus erythematosus revisitedKidney Int200465252153014717922

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