Ultrasound findings in renal parenchymal disease: comparison with histological appearances.

Ultrasound examination was carried out in 55 patients undergoing renal biopsy for suspected renal parenchymal disease. Analysis of sonographic and histological findings showed statistically significant positive correlations between renal size and the extent of glomerular hyper-cellularity and crescent formation and between cortical echogenicity and severity of glomerular sclerosis, crescent formation, interstitial inflammatory cell infiltration, tubular atrophy and interstitial fibrosis. Positive correlation was also observed between prominence of the medullary pyramids and glomerular sclerosis. The most marked sonographic abnormalities were seen in proliferative (including crescentic) glomerulonephritis, diabetic glomerulosclerosis and tubulo-interstitial nephritis. IgA, membranous and minimal change nephropathy were less likely to be associated with sonographic abnormalities. We conclude that certain sonographic appearances in renal parenchymal disease reflect the presence and severity of light microscopical abnormalities but, although ultrasound assessment provides a high positive predictive value for renal parenchymal disease, specific conditions cannot be distinguished.

Stromal cell populations in necropsy bone marrow sections from allogeneic marrow recipients and non-transplant patients.

AIMS: To compare the numbers of alkaline phosphatase positive reticulum cells (AL-RC) and macrophages in bone marrow transplant (BMT) recipients with numbers in normal subjects and to look for correlations with clinical features. METHODS: Sections of femoral marrow were obtained at necropsy from 18 BMT recipients and nine normal subjects who had died suddenly. AL-RC were visualised through their endogenous alkaline phosphatase activity. Macrophages were stained by an immunocytochemical technique using the antibody EBM/11 (CD68) and through their endogenous acid phosphatase activity. The numbers of stained cells were counted and expressed as a percentage of total nucleated cells. RESULTS: In both sets of marrow tissue, more macrophages stained for CD68 than for acid phosphatase, indicating macrophage heterogeneity. The percentage value for CD68 positive macrophages was higher among the transplant recipients (p < 0.01). At least in part this was caused by a reduction in haemopoietic cell numbers. Percentage values for acid phosphatase and alkaline phosphatase positive cells did not differ between the two groups. To exclude the effect of changes in marrow cellularity, stromal cell ratios were compared. The AL-RC: CD68 and acid phosphatase:CD68 ratios were both lower in BMT recipients, indicating that after BMT either the absolute number of AL-RC and acid phosphatase cells decreases, or CD68 cells increase, or there is a combination of the two. There was no correlation between the number of each cell type and cell dose given at transplantation, time after transplantation, presence of graft versus host disease or infection, marrow erythroid:myeloid ratio, or peripheral white cell count. The ratio of AL-RC to macrophages in our intact marrow was 0.43, considerably higher than that reported in cultured marrow. CONCLUSIONS: AL-RC and acid phosphatase positive cells may be most important for supporting haemopoiesis and their reduction after BMT may contribute to depression of haemopoiesis. CD68 positive cells include macrophages with a wide variety of functions and these may be increased in response to marrow damage.

Deep lamellar keratoplasty on air with lyophilised tissue.

Deep lamellar keratoplasty on air involves injecting air into the corneal stroma to expand it to several times its normal thickness. This method is designed to facilitate dissection of the deep stroma and reduce the risk of perforation of Descemet's membrane when carrying out deep lamellar keratoplasty. We have modified the technique by using prelathed freeze-dried donor tissue and report our results in a series of patients with corneal stromal scarring owing to a variety of corneal problems, namely, keratoconus, pterygium, and herpes zoster ophthalmicus. All patients achieved best corrected postoperative visual acuity of 6/12 or better without problems associated with graft failure or rejection. Histopathological examination of corneal tissue following air injection showed surgical emphysema within the cornea and separation of deep stromal fibres from the underlying Descemet's membrane.

ICAM-1 expression in renal disease.

AIM: To determine the role of intercellular adhesion molecule-1 (ICAM-1) in immune mediated damage in glomerulonephritis, and whether its expression correlates with disease activity. METHODS: Fifty three renal biopsy specimens from a range of non-immune renal disease and low grade and high grade glomerulonephritides were stained with ICAM-1. Positivity was assessed in the tubules. Tubular damage and accompanying interstitial inflammation were also noted. The ICAM-1 positivity in damaged and undamaged tubules was correlated with the three groups of renal disease. RESULTS: ICAM-1 positivity in undamaged tubules was observed in glomerulonephritis, and this showed a strong correlation with disease activity. In contrast, ICAM-1 positivity on damaged tubules correlated with evidence of chronic tubular damage, and was seen in a large proportion of cases, regardless of the underlying disease. There was no correlation between ICAM-1 positivity and a local lymphocytic infiltrate. CONCLUSION: ICAM-1 probably has an important role in the pathogenesis of glomerulonephritis. Its expression may be secondary to cytokines released by cells participating in the glomerular damage. As these cytokines also influence tubule function, tubular ICAM-1 expression may be a marker of the extent of tubular disturbance in glomerulonephritis.

Method for auditing turnround time in histopathology related to user requirements.

Histopathology audit schemes have concentrated on the accuracy of diagnosis or the standard of technical work. The most appropriate measure of specimen report time for histopathology was assessed. The simplest method is to calculate the mean or median number of days from receipt of specimens to issue of report, but this takes no account of clinical practice. An alternative approach is to compare the laboratory's performance with the clinicians' requirements. Clinicians were invited to complete a questionnaire specifying the reporting times they required subdivided by tissue type, clinical suspicion of malignancy, and bed occupancy of the patient. The questionnaire showed that there were distinct differences in clinicians' requirements. The turnround time for each category of specimen was calculated and expressed in three ways. The traditional method of quoting a median value showed very few differences among the categories. A comparison of the department's performance with the clinicians' requirements, using an arbitrary cut-off point of satisfying at least 80% of the clinicians' most stringent requirements or an achievement index, however, provided useful information for refining laboratory priorities.

Audit of general surgical pathology experience of histopathology trainees.

Surgical histopathology is learnt principally by the practical experience of reporting routine cases. This study performed a quantitative audit of the types of specimens reported by trainees at a teaching hospital and a district general hospital. At the teaching hospital all cases are seen by trainees and it was predicted that the distribution of specimens among trainees would be entirely random. Significant variations were found in the number of skin, breast, cervix, prostate, and endometrial cases reported by each trainee. In some cases this related to a trainee having a special interest (skin and breast pathology) or areas requiring special techniques (breast pathology). At the district general hospital the workload was much higher so that juniors did not see all cases and junior trainees were not seeing bronchial, liver, or lymph node biopsy specimens. This type of audit shows that in teaching hospitals specialisation by some trainees (as encouraged by the new MRCPath exam) may be to the detriment of others and that in district general hospitals pressure of work may actually reduce a trainee's exposure to difficult cases. Without systematic audit this would not be recognised and remedied.

Bone marrow stromal cell changes in haematological malignancies.

Stromal cell numbers from subjects with no haematological disease and those with acute myeloid leukaemia (AML), chronic granulocytic leukaemia (CGL), acute lymphatic leukaemia (ALL) and non-Hodgkin's lymphoma (NHL) were compared to determine their role in malignancy. Frozen sections of trephine biopsy specimens from iliac crests were stained for endogenous alkaline phosphatase activity, endogenous acid phosphatase activity, and, using immunocytochemical methods, for endothelial cells (anti-factor-VIII related antigen) and macrophages and related cells (EBM/11). In granulocytic malignancies, whether acute or chronic, alkaline phosphatase positive reticulum cells (AL-RC) and vascular endothelial cells were generally increased. In lymphoid malignancies, the numbers of AL-RC were generally reduced. Numbers of vascular endothelial cells seemed to be normal in ALL but reduced in foci of NHL. Macrophages are numerous in normal marrow, and their numbers seemed to be normal in granulocytic lesions but were more variable and sometimes reduced in ALL and NHL. Lymphoid malignancies, therefore, have a destructive effect on some stromal elements; granulocytic malignancies are associated with normal or increased numbers of stromal cells. A possible consequence of depleted stromal cells might be slower reconstitution of normal haemopoiesis after treatment. The large numbers in granulocytic malignancies raises the possibility of synergistic stimulation between stromal and neoplastic cells.

Kupffer cell numbers during human development.

Immunohistological assessment of Kupffer cells was made using the antibody MAC387 and an antibody to lysozyme. Autopsy liver samples from 13 fetuses aged from 17 weeks gestation to term, and from 10 neonates and children aged 1 day to 18 months, were studied. For comparison, 10 normal adult autopsy liver specimens were included. The number of positively staining cells per unit area was counted for periportal sinusoids (zone 1) and centrilobular sinusoids (zone 3). No difference was found between zone 1 and zone 3 macrophage numbers with either antibody at any stage of development. Hepatic sinusoidal macrophage numbers were low during early gestation but increased during intra-uterine life to reach approximately normal adult values in the neonatal period. The numbers of cells staining with MAC387 or lysozyme were similar in each case except for hepatic sinusoidal macrophages in fetuses of less than 30 weeks gestation. Here anti-lysozyme stained significantly fewer cells, suggesting that lysozyme production may be low in immature fetuses. No difference was found between infants of similar maturity who had died immediately or had lived for more than 48 h and hence been exposed to gut antigens.

Lymphocyte populations in autopsy bone marrow sections from recipients of allogeneic marrow and non-transplant sudden death cases.

Femoral marrow, obtained at autopsy, was stained using immunohistological techniques, for T (CD2+) cells, B (CD19+) cells, helper/inducer (CD4+) T cells, suppressor/cytotoxic (CD8+) T cells and natural killer (HNK1+) cells. The numbers present in 13 recipients of allogeneic marrow, 14 to 140 days after transplantation, were compared with those in marrows from nine subjects with no haematological or malignant conditions. In marrow sections from non-transplant subjects, approximately 8% nucleated cells were CD2+ with CD4+ and CD8+ cells present in nearly equal numbers; 1-3% were CD19+ and generally less than 1% HNK1+. The percentages of CD19+ and CD4+ cells were significantly reduced after bone marrow transplantation but, if a correction factor for marrow cellularity was introduced, then CD2+ and CD8+ cell values were also low. The findings were compared with the number of cells transplanted, the time after transplantation, presence of graft-versus-host disease or infection and peripheral blood white cell count, but no correlation was found.

Calcification of umbilical artery: two distinct lesions.

The clinical and pathological features of five cases of calcification of umbilical cord vessels were reviewed. Two distinct lesions were identified: calcification could produce either sclerosis of the wall or obliteration of the lumen. In three cases there was calcification within the media and adventitia of the umbilical arteries, with extension into Wharton's jelly in one case. The pathogenesis of this pattern of calcification--the sclerotic variant--is unclear but the findings of inflammation in the umbilical cord and its vessels, membranes, and decidua suggest intrauterine infection. In two cases there was complete calcification of umbilical arterial lumina resulting in total obliteration. The findings of fetal vessels in the chorionic plate with medial calcification in one of these two cases raises the possibility of thrombosis within the umbilical cord vessels as a cause, but the latter was not found. One infant from each group was liveborn. Both had shown signs of fetal distress in utero and delivered prematurely. The other three pregnancies resulted in macerated stillbirth preterm.

A new syndrome of autosomal recessive nephropathy, deafness, and hyperparathyroidism.

A consanguineous Pakistani family is described in which family members developed renal failure without haematuria, parathyroid hyperplasia, and sensorineural deafness. We believe the condition to be inherited as an autosomal recessive and to be distinct from Alport's syndrome, which is an X linked condition usually associated with haematuria.

Portal tract macrophages are increased in alcoholic liver disease.

Previous studies indicated decreased numbers and depressed clearance function of hepatic macrophages in alcoholic liver disease (ALD). We examined hepatic macrophages by immunohistochemical techniques in 45 liver biopsies from patients with a spectrum of ALD and compared them with 20 histologically normal biopsies from non-alcoholic patients. Antisera against lysozyme, alpha 1-antitrypsin (alpha 1AT) and a cytoplasmic molecule on macrophages (MAC-387) were used and the number of positively staining hepatic sinusoidal macrophages and portal tract macrophages assessed separately. Portal tract macrophage numbers were increased with all three markers in biopsies exhibiting only fatty change (P less than 0.05) and with MAC-387 in all ALD groups. In agreement with previous studies, lysozyme positive hepatic sinusoidal macrophages were decreased in all ALD groups. However, the other markers did not show any significant decrease and MAC-387 positive macrophages were increased in livers with cirrhosis plus hepatitis (P less than 0.01). The use of three markers revealed phenotypic heterogeneity of hepatic macrophages with antibodies to lysozyme and alpha 1 AT staining more hepatic sinusoidal macrophages than MAC-387, but MAC-387 and anti-lysozyme staining more portal tract macrophages than anti-alpha 1AT. Since hepatic macrophages appear to be heterogeneous and capable of diverse functions including the release of cytotoxic mediators, the finding of increased numbers, even in early ALD, suggests they may contribute to the increased numbers, even in early ALD, suggests they may contribute to the tissue damage.

Cellular composition of the spleen after human allogeneic bone marrow transplantation.

The cellular composition of the spleen has been assessed in 18 patients who died 15-326 days after receiving allogeneic marrow for leukaemia. The white pulp showed marked lymphocyte depletion with no germinal centres, very few B cells, and rare plasma cells. The marginal zone was unrecognizable but there were moderate numbers of T cells in the periarteriolar lymphatic sheaths (PALS), showing great variation in CD4/CD8 ratio. The percentage of CD4+ cells decreased with time post transplant. CD8+ cells were reduced in patients with graft-versus-host disease (GvHD) who also showed no increase in cells staining for activation markers. No T cells were detected expressing immature phenotypes and no differences were detected between patients who received marrow purged or unpurged of T cells. Macrophage numbers appeared normal. Extramedullary haemopoiesis (EMH) was predominantly in the red pulp greater than 30 days after transplantation but more commonly in the white pulp before then. Pyknotic cells were common in seven cases and appeared to be associated with EMH rather than GvHD. Chimaeric studies demonstrated small numbers of donor cells in the PALS at 26 days and larger numbers at 56 days.

Enlargement of the human spleen in graft-versus-host disease.

The spleens of 49 patients who had undergone allogeneic bone marrow transplantation for leukemia were compared at autopsy to determine the pathological changes associated with graft-versus-host disease (GVHD). The only significant finding was an increase in weight of about 1.7 times that of spleens from patients without GVHD. This was not explained by differences in the patients' sex, length of survival after transplantation, presence of infection, or liver pathology. On histological examination, there was no detectable increase in congestion, siderosis, or numbers of lymphocytes, macrophages, antigen-presenting cells, blast cells, pyknotic cells, plasma cells, or hemopoietic cells to explain the increase in spleen weight. On the contrary, there was actually a reduction in CD8+ T lymphocytes. No proliferative phase of GVHD could be identified, possibly due to a lack of specimens examined less than 8 days after transplantation and to prophylactic measures undertaken to minimize GVHD. The pathogenesis of splenomegaly in human GVHD is unclear.

Changes in rectal leucocytes after allogeneic bone marrow transplantation.

Using immunohistological techniques the number of leucocytes present in the epithelium and lamina propria of the rectal mucosa were assessed in 16 allogeneic bone marrow transplant recipients, with and without evidence of graft-versus-host disease (GVHD), and compared with a non-transplant group of patients. Samples were obtained between 15 and 198 days after transplant. In marrow recipients without GVHD, compared with non-transplant cases, there was a decrease in T lymphocytes in the lamina propria due to a reduction in the helper-inducer (T4+) subset with no change in suppressor-cytotoxic (T8+) cells or epithelial leucocytes. In GVHD, the number of T lymphocytes increased both in the lamina propria and epithelium due to an increase in T8+ cells with no change in T4+ cells. Lymphocytes did not express the activation markers detected by Tac, OKT10 or HLA-DR. Macrophages and natural killer cells were not changed after transplant or in GVHD. Epithelial HLA-DR expression was detected in seven out of eight in the GVHD group, three out of eight in the non-GVHD transplant group and two out of eight in the non-transplant cases. These findings show several differences from those we have observed in cutaneous and hepatic GVHD. Although elevated numbers of T8+ cells are common to GVHD in all three sites, the precise role of these cells in producing epithelial damage is not clear.