Ernesto O. Hoffmann M.D., Fred H. Rodriguez, M.D. and Syeda Sarwar, M.D.
Pathology and Laboratory Service, Veterans Medical Center and Department of Pathology, LSU Medical Center, New Orleans, Louisiana.
A. 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. 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. In the present page we introduce the use of a checklist in Systemic Lupus Erythematosus (SLE) biopsies. This is a complementary paper to the paper on "Una clasificacion facil para LES" published also in cin2000 (http://www.uninet.edu/cin2000)
B. Pathogenically SLE has two basic classes of glomerulonephritis, these may also be mixed. 1. The erroneously called proliferative GN (GN) (WHO classes IB, II-IV) is plainly called glomerulonephritis by WHO. We gave this GN a descriptive name: Pleomorphic (the deposits are of different sizes and shapes) pan glomerular glomerulonephritis (the deposits are lodged in all the components of the glomeruli) (PPGN). 2. Membranous GN (MBGN) (WHO class V). 3. A mixed GN which is a combined form of both PPGN and MBGN or mixed SLE GN (MXGN). The parameters to separate these basic groups are the immune complexes. 4. In addition there is a rare, fourth group (rare) of SLE nephritis, this has no glomerular component (interstitial nephritis, thrombotic micro agiopathy, vasculitis).
C. Based on the size, location, quantity and aggressivity of the immune complexes, PPGN may be separeted in three grades:
MBGN has two grades:
D. Complications are inconstant lesions superimposed on any of the previous groups of GN. These complications are more frequent and more numerous in the more aggressive forms. These complications may be active lesions (WHO active lesions) or chronic lesions (WHO sclerosing lesions).
There are also non-SLE super imposed lesions, not considered by WHO (ischemic sclerosis, FSGS, diabetic glomerulosclerosis, infections, others).
There are two parameters to be considered in grading active lesions (activity): the aggressivity of the lesion and its extent. Some lesions are reversible, self-limiting and do not leave scar nor abnormal function (effacement of podocytes, necrosis of tubular cells). Other lesions may or may not be reversible, may or may not leave scars and/or abnormal function (endothelio-mesangial cell proliferation, inflammation). 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. The extent of the lesion, involvement of glomeruli or renal parenchyma may be: focal (< 25%), limited (26-50%) or 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. We use Arabic numbers (0-3) for the grades and stages of the complications to avoid confusion with the grading of the basic lesions that have Roman numbers (0-III). Chronic lesions are measured by their extent only since most of them (if not all) are irreversible, most are scars and produce abnormal function. The chronic lesion may not be present, stage 0. They may be in an early stage of progression (<25 % involvement of glomeruli or cortical parenchyma) or stage 1. They may be in an intermediate stage (26-50%) or stage 2. Or they may be in an advanced stage (> 50%) or stage 3. Non-SLE lesions (complications) may also be graded and staged by the same parameters.
See page # 2 for the format used as a check list.
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.
3. Check List for SLE Renal Biopsies. Assessment of Activity and Chronicity. Cin2000. http://www.uninet.edu/cin2000.