ISO_639-1 en false 2014-06-08 Sabine Leh Haukeland University Hospital sabine.leh@helse-bergen.no in_development This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/. Nasjonal IKT Chang A, Gibson IW, Cohen AH, Weening JW, Jennette JC, and Fogo AB (2012). A position paper on standardizing the nonneoplastic kidney biopsy report. Hum Pathol 43:1192-1196. Farris AB, Adams CD, Brousaides N, Della Pelle PA, Collins AB, Moradi E, Smith RN, Grimm PC, and Colvin RB (2011). Morphometric and visual evaluation of fibrosis in renal biopsies. J Am Soc Nephrol 22:176-186. Berden AE, Ferrario F, Hagen EC, Jayne DR, Jennette JC, Joh K, Neumann I, Noel LH, Pusey CD, Waldherr R, Bruijn JA, and Bajema IM (2010). Histopathologic classification of ANCA-associated glomerulonephritis. J Am Soc Nephrol 21:1628-1636. Koss MN. Handling and interpretation of the medical renal biopsy (2014). Methods Mol Biol; 1180: 323-336 Racusen LC, Solez K, Colvin RB et al. The Banff 97 working classification of renal allograft pathology. Kidney International 1999; 55: 713-723 Solez K, Colvin RB, Racusen LC et al. Banff 07 classification of renal allograft pathology: Updates and future directions. American Journal of Transplantation 2008; 8: 753-760 Jennette JC, D'Agati VD, Olson JL, Silva F. Heptinstall's Pathology of the Kidney. LWW, Philadelphia: 2014; Weening JJ, D'Agati VD, Schwartz MM, Seshan SV, Alpers CE, Appel GB, Balow JE, Bruijn JA, Cook T, Ferrario F, Fogo AB, Ginzler EM, Hebert L, Hill G, Hill P, Jennette JC, Kong NC, Lesavre P, Lockshin M, Looi LM, Makino H, Moura LA, Nagata M. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol. 2004 Feb;15(2):241-50. Erratum in: J Am Soc Nephrol. 2004 Mar;15(3):835-6. Working Group of the International IgA Nephropathy Network and the Renal Pathology Society, Roberts IS, Cook HT, Troyanov S, Alpers CE, Amore A, Barratt J, Berthoux F, Bonsib S, Bruijn JA, Cattran DC, Coppo R, D'Agati V, D'Amico G, Emancipator S, Emma F, Feehally J, Ferrario F, Fervenza FC, Florquin S, Fogo A, Geddes CC, Groene HJ, Haas M, Herzenberg AM, Hill PA, Hogg RJ, Hsu SI, Jennette JC, Joh K, Julian BA, Kawamura T, Lai FM, Li LS, Li PK, Liu ZH, Mackinnon B, Mezzano S, Schena FP, Tomino Y, Walker PD, Wang H, Weening JJ, Yoshikawa N, Zhang H. The Oxford classification of IgA nephropathy: pathology definitions, correlations, and reproducibility. Kidney Int. 2009 Sep;76(5):546-56. Sabine Leh, Haukeland University Hospital, sabine.leh@helse-bergen.no no.nasjonalikt Nasjonal IKT no.nasjonalikt 45ED5CF84F253443E59D1D1B2084F07C be1b5cc5-9918-4c14-99ff-1709f66d79f4 0.0.1-alpha

ISO_639-1 en To record detailed findings about a non-neoplastic renal biopsy histopathology pathology renal laboratory To record detailed findings about microscopic examination of tissue related to glomerular, tubulointerstitial and vascular renal diseases. Use as a component archetype in the context of a suite of archetypes that make up a histopathology report i.e. OBSERVATION.lab_test.histopathology Not designed to be used within any other archetype other than OBSERVATION.lab_test.histopathology. © Nasjonal IKT HF

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Cortex Cortical tissue present, alternatively core length with cortical tissue, alternatively proportion of cortical tissue in relation to the core with renal tissue. Present Cortical tissue present. Absent Cortical tissue absent. Indeterminate Presence of cortical tissue has not been determined. Medulla Medullary tissue present, alternatively core length with medullary tissue, alternatively proportion of medullary tissue in relation to the core with renal tissue. Present Medullary tissue present. Absent Medullary tissue absent. Indeterminate Presence of medullary tissue has not been determined. Renale capsule A statement whether the renal capsule is present. Other tissue elements Description of other tissue elements, e.g. muscle tissue. Sceletal muscle and/or fat tissue and/or connective tissue Sceletal muscle and/or fat tissue and/or connective tissue present. Renal pelvis mucosa Renal pelvis mucosa present. Glomeruli Description of glomerular changes. Glomeruli The maximum number of glomeruli irrespective of size present in one section; structures consisting of Bowman's capsule with empty Bowman's space are excluded. Scorable glomeruli The number of glomeruli judged as adequate for scoring by the reporting pathologist. Glomeruli solely with necrosis The number of glomeruli showing fibrinoid necrosis without crescent formation. Glomeruli with crescents The number of glomeruli showing cellular or fibrocellular crescents. Glomeruli with ischemic changes The number of glomeruli showing some degree of tuft retraction and wrinkling of capillary walls. Chronic ischemic changes might show fibrosis of Bowman's capsule. Glomeruli with segmental sclerosis The number of glomeruli showing obliteration of capillary lumen by extracellular matrix in a portion of the tuft area with or without adhesions to the Bowman capsule, hyaline lesions, foam cells. Glomeruli with global sclerosis The number of glomeruli showing scarring with obliteration of capillary lumen by extracellular matrix in the entire or nearly entire glomerular tuft. Normal glomeruli The number of glomeruli which appear normal without major changes. Description of glomeruli A narrative description of glomerular findings, e.g. mesangial and endocapillary cellularity, capillary wall changes, podocytes, Bowman's space. For structured description of specific renal diseases use appropriate cluster (IgA nephropathy, lupus nephritis). Details of specific glomerular changes Slot for detailed description of specific glomerular changes. Include: openEHR-EHR-CLUSTER.glomerulus_segmental_glomerulosclerosis_classification.v1. Tubules Description of tubular changes. Tubular casts Structured report of kind of tubular casts present. Myeloma casts Characteristic myeloma casts, often surrounded by reactive tubular epithelial cells. or multinucleated cells, present in tubular lumen. Tamm Horsfall protein Presence of intratubular Tamm Horsfall protein. Hyaline casts Presence of hyalin casts in tubular lumen. Granular casts Presence of granular casts in tubular lumen. Detached cells Detached cells, commonly epithelial cells, present in the tubular lumen. Red blood cells Collections of red blood cells or red blood cell casts present in tubular lumen. Granulocytes Presence of neutrophil granulocytes in tubular lumen. Crystals Crystals present in tubular lumen. Tubular atrophy Semiquantitative or quantitative assessment of tubular atrophy. Tubular atrophy semiquantitative Semiquantitative visual assessment of tubular atrophy. Absent Tubular atrophy is not present or minimal (few transsections). Slight Tubular atrophy in up to 25 % of the area of cortical tubules. Moderate Tubular atrophy involving 25 - 50% of the area of cortical tubules. Severe Tubular atrophy present in more than 50% of the area of cortical tubules. Indeterminate Tubular atrophy could not be assessed, e.g. due to bad sections. Tubules description Desription of tubular changes, e.g. hyalin droplet change, acute epithelial damage, cytoplasmic vacuolation, sloughing of cells, loss of brush border. Interstitium Interstitial changes, especially semiquantitative or quantitative assessment of interstitial fibrosis. Quantification of interstitial fibrosis Quantification of interstitial fibrosis by image analysis methods. Image analysis details To record details of the image analysis, e.g. software, algorithm. Technique Technique used to quantify fibrosis. Sirius red unpolarized Sirius red stain unpolarized used for fibrosis quantification by image analysis Sirius red polarized Sirius red stain polarized used for fibrosis quantification by image analysis Collagen III immunohistochemistry Collagen III immunohistochemical stain used for fibrosis quantification by image analysis Percentage interstitial fibrosis Percentage of the renal cortical tissue involved by fibrosis. Cortical area with fibrosis estimated Visual quantification of interstitial fibrosis; The fibrosis percentage is the percentage of abnormal cortical tissue with fibrosis. Fibrous tissue estimated Visual quantification of interstitial fibrosis; The fibrosis percentage is the percentage of all cortical tissue (excluding tubules and glomeruli) occupied by fibrous tissue. Interstitium description Description of interstitial changes, e.g. edema, inflammatory cells, deposits. Vasculature Changes affecting arteries, arterioles, venes and peritubular capillaries. Number of arteries Number of arteries in a renal biopsy. Arteriosclerosis Amount of arteriosclerosis in the most affected vessel. Not present/minimal There is no intimal sclerosis or intimal sclerosis is minimal. Mild There is < 25% lumen narrowing by intimal fibrosis. Moderate There is 25% - 50% lumen narrowing by intimal fibrosis. Severe There is > 50% lumen narrowing by intimal fibrosis. Arteriolosclerosis Amount of arteriolosclerosis in the most affected vessel. Absent Arteriolosclerosis not present. Present - nodular Nodular arteriolosclerosis is present. Present - circumferential Circumferential arteriolosclerosis is present. Vasculature description Description of vascular changes, e.g. vasculitis, venulitis. For description of severity of arteriosclerosis and arteriolosclerosis use coded text. Amyloid Findings related to amyloid deposition. Details of amyloid deposition Slot for detailed description of specific glomerular changes. Include: openEHR-EHR-CLUSTER.amyloid_deposition.v1 Specific clinical situations Detailed structured description for specific clinical situations, e.g. biopsy of renal transplant, lupus nephritis, IgA nephropathy. Multimedia representation Images from lesions could be attached here. Multimedia representation of image analysis Images, graphs and tables from automatic image analysis of interstitial fibrosis. Casts in tubules Choose the type of casts present in tubuli. Multiple choices possible. Mixed casts Casts consisting of more than one component. Pigmented casts Discolorated casts e.g. due to hemoglobin, myoglobin, drug pigments, bilirubin, melanin. Podocytes Description of podocyte changes. Hypertrophy Enlarged podocytes often with amphophil cytoplasm. Absent Podocyte size is normal. Slight Podocytes are slightly enlarged. Moderate Podocytes are moderately enlarged. Severe Podocytes are severely enlarged. Bi- or multinucleated podocytes Podocytes with 2 or more nuclei. Absent Bi- or multinucleated podocytes are not seen. Present Bi- or multinucleated podocytes are seen. Indeterminate Presence of bi- or mulitnucleated podocytes has not been determined. Equivocal Presence of bi- or mulitnucleated podocytes is equivocal. Resorption droplets Podocytes with PAS positive resorption droplets. Absent Podocytes with resorption droplets are not present. Singular cells One or few podocytes with resorption droplets are present. Numerous cells Numerous podocytes with resorption droplets are present. Indeterminate Presence of podocytes with resorption droplets could not be assessed, e.g. due tof bad morphology. Equivocal It is uncertain whether podocytes with resorption droplets are present or not. Pseudocysts Podocytes with pseudocysts. Absent Podocytes with resorption droplets are not present. Singular One of few podocytes with resorption droplets are present. Numerous Numerous podocytes with resorption droplets are present. Equivocal It is uncertain whether podocytes with resorption droplets are present or not. Indeterminate Presence of podocytes with resorption droplets could not be assessed, e.g. due to bad morphology. Equivocal It is uncertain whether podocyte size is normal or enlarged. Indeterminate Podocyte size could not be assessed, e.g. due to bad morphology. Mesangium Description of mesangial changes. No abnormality detected Statement that no abnormality was detected on examination of the mesangial areas. No abnormality detected Statement that no abnormality was detected on examination of podocytes. Details of the mesangium A narrative description of mesangial changes. Mesangial matrix increase Visual assessment of the amount of mesangial matrix. Absent Mesangial matrix is not increased. Slight Mesangial matrix is slightly increased. Moderate Mesangial matrix is moderately increased. Severe Mesangial matrix is severely increased. Equivocal It is uncertain, whether mesangial matrix is increased. Details of podocytes A narrative description of podocyte changes. Indeterminate Mesangial matrix increase could not be assessed. e.g. due to bad morphology. Mesangial hypercellularity A visual assessment of the cellularity of the mesangium. Normally there are 1 - 3 cells per mesangial area. The score is based on the most cellular mesangial area. Mesangial areas adjacent to the vascular stalk should not be scored. Definitions based on Roberts et al, 2009. Absent There is no increase in mesangial cells. Slight There is a slight increase in mesangial cellularity, usually 4-5 cells per mesangial area. Moderate There is a moderate increase in mesangial cellularity, usually 6-7 cells per mesangial area. Severe There is a severe increase in mesangial cellularity, usually 8 or more cells per mesangial area. Equivocal It is uncertain whether there is an increase in mesangial cellularity or not. Indeterminate Mesangial cellularity could not be assessed, e.g. due to bad morphology or thick sections. Capillaries Description of glomerular capillary changes. No abnormality detected Statement that no abnormality was detected on examination of the glomerular capillaries. Capillary wall thickening A visual assessment of the capillary wall thickness. Details of glomerular capillaries A narrative description of glomerular capillary changes. Absent Glomerular capillary walls are not thickened. Focal Glomerular capillary walls are focally thickened. Diffuse Glomerular capillary walls are diffusely thickened. Segmental Glomerular capillary walls are segmentally thickened. Global Glomerular capillary walls are globally thickened. Equivocal It is uncertain whether glomerular capillary walls are thickened. Indeterminate Glomerular capillary wall thickness could not be assessed, e.g. due to section thickness. Capillary wall duplication A visual assessment of the presence of capillary wall duplication. Absent Capillary wall duplication is not present. Focal Capillary wall duplication is focally present. Diffuse Capillary wall duplication is diffusely present. Segmental Capillary wall duplication is segmentally present. Global Capillary wall duplication is globally present. Equivocal It is unceratin whether capillary wall duplication is present. Indeterminate Capillary wall thickening could not be assessed, e.g. due to bad morphology. Capillary lumen Description of changes in the capillary lumens. Endocapillary hypercellularity Visual assessment of endocapillary hypercellularity. Absent Endocapillary hypercellularity is not present. Focal Endocapillary hypercellularity is focally present. Diffuse Endocapillary hypercellularity is diffusely present. Segmental Endocapillary hypercellularity is segmentally present. Global Endocapillary hypercellularity is globally present. Equivocal It is uncertain whether there is endocapillary hypercellularity. Indeterminate Endocapillary cellularity could not be assessed, e.g. due to bad morphology. Thrombi Visual assessment of intracapillary thrombi. Absent Intracapillary thrombi are absent. Endocapillary hypercellularity Findings related to endocapillary cellularity. Cell type Composition of intracapillary cells. Endothelial cells Endothelial cells are part of the intracapillary infiltrate. Macrophages Macrophages are part of the intracapillary infiltrate. Neutrophil granulocytes Neutrophil granulocytes are part of the intracapillary infiltrate. Lymphocytes Lymphocytes are part of the intracapillary infiltrate. Atypical cells Atypical cells are part of the intracapillary infiltrate. Focal Intracapillary thrombi are present in less than half of the glomeruli. Diffuse Intracapillary thrombi are present in more than half of the glomeruli. Segmental Intracapillary thrombi are present only in a part of the glomerular tuft. Global Intracapillary thrombi are present in the whole glomerular tuft. Equivocal It is uncertain whether intracapillary thrombi are present or not. Indeterminate Presence of intracapillary thrombi could not be assessed, e.g. because of bad sections. Thrombi Findings related to intracapillary thrombi. Thrombus type Type of intracapillary thrombi. Hyalin The intracapillary thrombi are mainly hyalinous. Fibrin The intracapillary thrombi consist mainly of fibrin. Mesangial cell interposition A visual assesment of the presence of interposed cells in the capillary periphery. Present Mesangial interposition is present. Absent Mesangial interposition is absent. Equivocal It is uncertain whether mesangial interposition is present. Indeterminate Mesangial interposition could not be assessed, e.g. because of bad sections. Mesangial nodularity A visual assessment of the presence of acellular PAS positive mesangial nodules. Absent Mesangial nodules are absent. Present Mesangial nodules are present. Equivocal It is uncertain whether mesangial nodules are present. Indeterminate Presence of mesangial nodules could not be assessed, e.g. because of bad sections. Tubular epithelial cell changes Description of tubular epithelial cell changes. Multiple choices possible. Hyaline droplet change PAS positive absorption droplets in the epithelium of proximal tubules, usually indicating glomerular proteinuria. Fine vacuolization Fine, even vacuolization of the proximal tubular epithelium. Hydropic change is a synonym. If related to infusion of hypertonic solutions, the change is also described as osmotic nephrosis. If related to cyclosporin therapy, the change is called isometric vacuolization. Coarse vacuolization Irregular and coarse vacuolization of the tubular epithelium. The change might be associated with hypokaliemia or tubulotoxicity. Fatty change Fine vacuoles containing lipid, often at the base of the tubular epithelial cells. Fat can be demonstrated by lipid stains on frozen sections. Giant mitochondria Enlarged mitochondria visuable as eosinophilic bodies in tubular epithelial cells. Glomeruli with adhesions The number of glomeruli showing coneective tissue connections between the tuft and Bowman's capsule without overt sclerosis. No abnormality detected A statement that no abnormality was detected in renal tubules. No abnormality detected A statement that no abnormality was detected in the renal interstitium. No abnormality detected A statement that no abnormality was detected in the renal vasculature. Amyloid not detected A statement that no amyloid deposition was detected.