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MBGN page 1a (Index) / GNMB page 1a (Indice))

 CHECK LIST FOR MEMBRANOUS GLOMERULONEPHRITIS (MBGN)
Assessment of activity and chronicity

A. Check lists: Check lists have been introduced in surgical pathology (tumor pathology) to make the study of the biopsies more organized, avoid omissions, make the pathology reports more uniform and complete, and improve communications with the clinicians (1). In our experience these checklists are also very helpful to gather information from renal biopsies and to grade and stage the lesions in the nephropathies (2,3). In the present page we introduce the use of a checklist in Membranous Glomerulonephritis.

B. Adequacy of the biopsy: In renal pathology a renal biopsy with at least ten glomeruli is usually adequate for diagnosis but more than twenty glomeruli must be obtained for diagnosis and adequate assessment of activity (GRADE) and chronicity (STAGE). In MBGN a diagnosis may be possible with a segment of a glomerulus. But for quantitative analysis this material will not be adequate (4-6).
Adequate biopsy: Ten or more glomeruli.
Conditional biopsy: One to ten non-sclerotic glomeruli.
Inadequate biopsy: No glomeruli

C. Glomerular Stage: The WHO has classified MBGN according to the stage (progression) of the sub epithelial deposits in four groups (7,8).
Stage I: The deposits have not penetrated the GBM (no spikes)
Stage II: The deposits have partially penetrated the GBM (spikes are obvious)
Stage III: The deposits have totally penetrated the GBM (segmental spikes)
Stage IV: Reabsorption of the deposits is extensive (no spikes)

D. Signs of activity: There are two parameters to be considered in grading active lesions (activity). A. Aggressivity of the lesion: a. Some lesions are reversible, self-limiting and do not leave scar nor abnormal function (effacement of podocytes, necrosis of tubular cells). b. Other lesions may or may not be reversible, may or may not leave scars and/or abnormal function (endothelio-mesangial cell proliferation, inflammation, and immune deposits). c. Still other lesions are irreversible, leave scars and abnormal function (necrosis, crescents, thrombosis). This parameter must be balanced with the extent of the active lesion. B. Extent of the lesion: The involvement of glomeruli or renal parenchyma may be: a. focal (< 25%), b. limited (26-50%) or c. diffuse (> 50%). The assessment of activity is rather subjective since aggressiveness of the lesion must be balanced with the extent of the lesion to obtain the grade of activity. This grade of activity may be: 0 none, 1 mild, 2 moderate or 3 severe.

E. Signs of chronicity: Chronic lesions are measured by their extent only since most of them (if not all) are irreversible, most are scars and produce abnormal function. Stage 0: The chronic lesion is not present. Stage 1, early: The lesion is in an early stage of progression. Less than 25 % of glomeruli or cortical parenchyma are involved. Stage 2, intermediate: 26-50% of glomeruli or cortical parenchyma is involved. Stage 3, advanced: More than 50% of glomeruli or cortical parenchyma are involved. Non MBGN lesions (Superimposed morphologic patterns) may also be graded and staged by the same parameters.

F. Superimposed Morphologic Patterns: MBGN may be coincidental with other morphologic patterns usually associated to other processes. Thin membrane disease, MPGN, diabetic glomerulosclerosis, IgA nephropathy, benign nephrosclerosis, others.

G. References:
1. Association of Directors of Anatomic and Surgical Pathology: Standardization of the Surgical Pathology Report. Am J Surg Pathol 16:84-86, 1992.

2. E.O. Hoffmann: Una Clasificacion Practica para la Nefritis Lupica. Cin2000. (Click here)

3. Check List for SLE Renal Biopsies. Assessment of Activity and Chronicity. Cin2000 (Click here)

4. Colwin HL, Schwartz MM, Lewis EJ: The importance of sample size in the interpretation of renal biopsy. Am J Nephrol 8:85-89, 1990.

5. Wang HJ, Solez K, Cockfield SM, Kjellstrad C: The reliability of the baseline renal allograft biopsy predicting allograft outcome. Departments of Medicine and Pathology. University of Alberta, Edmonton, Alberta, Canada.

6. Feinstein AR,Sosin DM, Wells CK: The Will Rogers Phenomenon: stage migration and new diagnostic techniques as a source of misleading survival statistics for survival in cancer. New Engl J Med 312:1604-1608, 1985.

7. Heptinstall RH (1992): Pathology of the Kidney. Little and Brown and Co, Boston.

8. Tisher CC, Brenner BM (1994): Renal Pathology. Lippincott Co, Philadelphia.

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Biopsy is:

Adequate:

Conditional:

Inadequate:

Glomerular Stage	WHO I	WHO II	WHO III	WHO IV
	-	-	-	-
Signs of Activity	None 0	Mild (1)	Moderate (2)	Severe (3)
Gl cell proliferation	-	-	-	-
Active crescents	-	-	-	-
Interstitial inflammation	-	-	-	-
Renal vein thrombosis	-	-	-	-
Other	-	-	-	-
Signs of Chronicity	None 0	Early (1)	Intermediate (2)	Advanced (3)
Gl fibrosis-sclerosis (old crescents)	-	-	-	-
Tubular atrophy	-	-	-	-
Interstitial fibrosis	-	-	-	-
Arteriosclerosis	-	-	-	-
Arteriolosclerosis	-	-	-	-
Other	-	-	-	-
Superimposed Patterns (Other nephropathies)	None 0	Mild (1)	Moderate (2)	Severe (3)
FSGS	-	-	-	-
IgA (Berger's)	-	-	-	-
Thin Membrane NP	-	-	-	-
Diabetic glomerulosclerosis	-	-	-	-
MPGN	-	-	-	-
Other	-	-	-	-
Underlying diseases (Clinically confirmed)	None 0	Yes	No	--
Idiopathic	-	-	-	-
Autoimmune	-	-	-	-
Neoplasia	-	-	-	-
Infections	-	-	-	-
Drugs	-	-	-	-
Other	-	-	-	-

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