TEMPLATE Kidney biopsy use case 1 (Kidney biopsy use case 1)

TEMPLATE ID	Kidney biopsy use case 1
Concept	Kidney biopsy use case 1
Description	Not Specified
Purpose	Not Specified
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Language used	nb
Citeable Identifier	1078.60.670
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Rapport	Rapport: Dokument som brukes for å kommunisere informasjon til andre, ofte som svar på en forespørsel.
Other Context
Rapport ID	Rapport ID: Rapportidentifikator.
Status	Status: Status for hele rapporten. NB: Dette er ikke status for enkeltkomponentene i rapporten.
Laboratoriesvar	Laboratoriesvar: Funn og tolkning av laboratorieanalyse utført på prøvemateriale fra pasient. Denne arketypen kan brukes for å registrere en enkeltverdi av en analyse, men vil ofte bli spesialisert eller lagt inn i en templat for å representere flere verdier eller pakker av analyser. Denne arketypen fungerer også som forelder for spesialiserte laboratoresvar-arketyper, for eksempel mikrobiologi eller patologi.
Data	Data: *@ internal @(en)
Uspesifisert hendelse	Uspesifisert hendelse: Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i en templat eller i en applikasjon.
Data	Data: *@ internal @(en)
Kidney biopsy	Kidney biopsy: Identifikasjon av den utførte analysen, av og til inkludert prøvetype og pasientens tilstand Et prøveresultat kan gjelde for en enkelt analyse eller en gruppe av analyser, inkludert analysepakker. Koding med en terminologi, eventuelt med en prekoordinert term inkludert prøvetype er å foretrekke, hvis mulig. Kan bli kodet med LOINC eller SNOMED CT eller nasjonale laboratoriekodeverk. Eksempler kan være "Glukose", "Urea og elektrolytter", "Dyrkning", "Kortisol (morgen)" eller "Leverbiopsi".
Specimen	Specimen: To record details of a laboratory specimen.
Datetime collected	Datetime collected: The date and time that collection has been ordered to take place or has taken place.
Specimen collector identifier	Specimen collector identifier: Identifier of the person or agency responsible for collecting the specimen. Optional[{fhir_mapping=Specimen.collection.collector}]
Number of containers	Number of containers: The total number of containers holding this specimen. >=0
Specimen quality	Specimen quality: Problems with the received specimen.
Comment	Comment: An additional text comment on the quality of the received specimen.
Processing	Processing: Workflow of specimen processing/handling.
Datetime received	Datetime received: The date and time that the sample was received at the laboratory. Optional[{fhir_mapping=Specimen.receivedTime}]
Laboratory specimen identifier	Laboratory specimen identifier: Unique identifier of the specimen, normally assigned by the laboratory. Sometimes called the Accession Identifier. Optional[{fhir_mapping=Specimen.accessionIdentifier}] Annotations Notes.Question: Is this where you put the overall Biopsy number?
Analysestatus	Analysestatus: Overordnet status på analyseresultatet. Registrert Delvis Endelig Korrigert Revidert Kansellert Feilregistrert
Dato/tid svarrapport	Dato/tid svarrapport: Dato og/eller tidspunkt hele svaret var utstedt for svarrapporten.
Tilgjengelig klinisk informasjon	Tilgjengelig klinisk informasjon: Beskrivelse av klinisk informasjon som er tilgjengelig på tolkningstidspunktet, noe som kan inkludere en lenke til den originale kliniske informasjonen som ble gitt i rekvisisjonen. I HL7 FHIR lagres denne informasjonen innen lenket requestDetail.clinical.
Container 1	Container 1: Findings and interpretation of histopathology (anatomic pathology) tests performed on tissues and body fluids.
Macroscopic findings	Macroscopic findings: A group of findings within the histopathology examination. The Runtime name constraint allows identification of the type of histopathology examination performed.
Histopathology finding	Histopathology finding: Details of an individual histopathology finding, often related to a specific anatomical location or specimen.
Tissue available	Tissue available: True if the tissue is available for examination.
Specimen	Specimen: To record details of a laboratory specimen.
Fysiske egenskaper til et objekt	Fysiske egenskaper til et objekt: For registrering av de fysiske egenskaper til et objekt som en kroppsdel eller en lesjon.
Navn på det fysiske objektet	Navn på det fysiske objektet: Den aktuelle gjenstanden. Kan være en kroppsdel, enhet eller prøve. Needle core biopsy
Dimensjon	Dimensjon: Dimensjonene til objektet.
Lengde	Lengde: Lengden til objektet.
Bilde	Bilde: Bilde av objektet.
Fysiske egenskaper til et objekt #1	Fysiske egenskaper til et objekt #1: For registrering av de fysiske egenskaper til et objekt som en kroppsdel eller en lesjon.
Navn på det fysiske objektet	Navn på det fysiske objektet: Den aktuelle gjenstanden. Kan være en kroppsdel, enhet eller prøve. Needle core biopsy
Dimensjon	Dimensjon: Dimensjonene til objektet.
Lengde	Lengde: Lengden til objektet.
Bilde	Bilde: Bilde av objektet.
Specimen container	Specimen container: Details of a specimen container. This is often integral to workflow and reporting of pathology specimens, particularly anatomical and histological pathology specimens.
Container additive	Container additive: Any special fixative or transport medium requirements.
Description	Description: A narrative description of the histopathology finding.
Description	Description: A narrative description of the group of histopathology findings.
Microscopic findings	Microscopic findings: A group of findings within the histopathology examination. The Runtime name constraint allows identification of the type of histopathology examination performed.
Histopathology finding	Histopathology finding: Details of an individual histopathology finding, often related to a specific anatomical location or specimen.
Description	Description: A narrative description of the histopathology finding. Annotations Notes.Reviewers Note: Immunhistokjemi CLUSTER ikke laget enda. Må legges inn under strukturerte funn.
Microscopy renal biopsy non neoplastic	Microscopy renal biopsy non neoplastic: Microscopic findings related to a non-neoplastic renal biopsy
Renal biopsy overall description	Renal biopsy overall description: Describes tissue types in the renal biopsy specimen.
Cortex	Cortex: Cortical tissue present, alternatively core length with cortical tissue, alternatively proportion of cortical tissue in relation to the core with renal tissue. Kodet tekst Present Absent Indeterminate KvantitetEnheter: mm Proporsjon Prosent
Medulla	Medulla: Medullary tissue present, alternatively core length with medullary tissue, alternatively proportion of medullary tissue in relation to the core with renal tissue. Kodet tekst Present Absent Indeterminate KvantitetEnheter: mm Proporsjon Prosent
Renale capsule	Renale capsule: A statement whether the renal capsule is present.
Other tissue elements	Other tissue elements: Description of other tissue elements, e.g. muscle tissue. Kodet tekst Sceletal muscle and/or fat tissue and/or connective tissue Renal pelvis mucosa Fri eller kodet tekst
Glomeruli	Glomeruli: Description of glomerular changes.
Glomeruli	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	Scorable glomeruli: The number of glomeruli judged as adequate for scoring by the reporting pathologist.
Glomeruli solely with necrosis	Glomeruli solely with necrosis: The number of glomeruli showing fibrinoid necrosis without crescent formation.
Glomeruli with crescents	Glomeruli with crescents: The number of glomeruli showing cellular or fibrocellular crescents.
Glomeruli with ischemic changes	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 adhesions	Glomeruli with adhesions: The number of glomeruli showing coneective tissue connections between the tuft and Bowman's capsule without overt sclerosis.
Glomeruli with segmental sclerosis	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	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	Normal glomeruli: The number of glomeruli which appear normal without major changes.
Mesangium	Mesangium: Description of mesangial changes.
No abnormality detected	No abnormality detected: Statement that no abnormality was detected on examination of the mesangial areas.
Details of the mesangium	Details of the mesangium: A narrative description of mesangial changes.
Mesangial matrix increase	Mesangial matrix increase: Visual assessment of the amount of mesangial matrix. Kodet tekst Absent Slight Moderate Severe Equivocal Indeterminate Boolsk
Mesangial hypercellularity	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. Kodet tekst Absent Slight Moderate Severe Equivocal Indeterminate Boolsk
Mesangial nodularity	Mesangial nodularity: A visual assessment of the presence of acellular PAS positive mesangial nodules. Kodet tekst Absent Present Equivocal Indeterminate Boolsk
Capillaries	Capillaries: Description of glomerular capillary changes.
No abnormality detected	No abnormality detected: Statement that no abnormality was detected on examination of the glomerular capillaries.
Details of glomerular capillaries	Details of glomerular capillaries: A narrative description of glomerular capillary changes.
Capillary wall thickening	Capillary wall thickening: A visual assessment of the capillary wall thickness. Kodet tekst Absent Focal Diffuse Segmental Global Equivocal Indeterminate Boolsk
Capillary wall duplication	Capillary wall duplication: A visual assessment of the presence of capillary wall duplication. Boolsk Kodet tekst Absent Focal Diffuse Segmental Global Equivocal Indeterminate
Mesangial cell interposition	Mesangial cell interposition: A visual assesment of the presence of interposed cells in the capillary periphery. Fri eller kodet tekst Kodet tekst Present Absent Equivocal Indeterminate
Capillary lumen	Capillary lumen: Description of changes in the capillary lumens.
Thrombi	Thrombi: Findings related to intracapillary thrombi.
Thrombi	Thrombi: Visual assessment of intracapillary thrombi. Kodet tekst Absent Focal Diffuse Segmental Global Equivocal Indeterminate Fri eller kodet tekst
Thrombus type	Thrombus type: Type of intracapillary thrombi. Hyalin Fibrin
Endocapillary hypercellularity	Endocapillary hypercellularity: Findings related to endocapillary cellularity.
Endocapillary hypercellularity	Endocapillary hypercellularity: Visual assessment of endocapillary hypercellularity. Kodet tekst Absent Focal Diffuse Segmental Global Equivocal Indeterminate Boolsk
Cell type	Cell type: Composition of intracapillary cells. Fri eller kodet tekst Kodet tekst Endothelial cells Macrophages Neutrophil granulocytes Lymphocytes Atypical cells
Podocytes	Podocytes: Description of podocyte changes.
No abnormality detected	No abnormality detected: Statement that no abnormality was detected on examination of podocytes.
Details of podocytes	Details of podocytes: A narrative description of podocyte changes.
Hypertrophy	Hypertrophy: Enlarged podocytes often with amphophil cytoplasm. Kodet tekst Absent Slight Moderate Severe Equivocal Indeterminate Fri eller kodet tekst Boolsk
Bi- or multinucleated podocytes	Bi- or multinucleated podocytes: Podocytes with 2 or more nuclei. Absent Present Equivocal Indeterminate Antatt verdi: Absent
Resorption droplets	Resorption droplets: Podocytes with PAS positive resorption droplets. Absent Singular cells Numerous cells Equivocal Indeterminate
Pseudocysts	Pseudocysts: Podocytes with pseudocysts. Absent Singular Numerous Equivocal Indeterminate
Description of glomeruli	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).
Tubules	Tubules: Description of tubular changes.
No abnormality detected	No abnormality detected: A statement that no abnormality was detected in renal tubules.
Tubular epithelial cell changes	Tubular epithelial cell changes: Description of tubular epithelial cell changes. Multiple choices possible. Hyaline droplet change Fine vacuolization Coarse vacuolization Fatty change Giant mitochondria
Casts in tubules	Casts in tubules: Choose the type of casts present in tubuli. Multiple choices possible. Tamm Horsfall protein Hyaline casts Granular casts Detached cells Red blood cells Granulocytes Mixed casts Pigmented casts Myeloma casts Crystals
Tubular casts	Tubular casts: Structured report of kind of tubular casts present.
Tamm Horsfall protein	Tamm Horsfall protein: Presence of intratubular Tamm Horsfall protein.
Hyaline casts	Hyaline casts: Presence of hyalin casts in tubular lumen.
Granular casts	Granular casts: Presence of granular casts in tubular lumen.
Detached cells	Detached cells: Detached cells, commonly epithelial cells, present in the tubular lumen.
Red blood cells	Red blood cells: Collections of red blood cells or red blood cell casts present in tubular lumen.
Granulocytes	Granulocytes: Presence of neutrophil granulocytes in tubular lumen.
Mixed casts	Mixed casts: Casts consisting of more than one component.
Pigmented casts	Pigmented casts: Discolorated casts e.g. due to hemoglobin, myoglobin, drug pigments, bilirubin, melanin.
Myeloma casts	Myeloma casts: Characteristic myeloma casts, often surrounded by reactive tubular epithelial cells. or multinucleated cells, present in tubular lumen.
Crystals	Crystals: Crystals present in tubular lumen.
Tubular atrophy	Tubular atrophy: Semiquantitative or quantitative assessment of tubular atrophy.
Tubular atrophy semiquantitative	Tubular atrophy semiquantitative: Semiquantitative visual assessment of tubular atrophy. Absent Slight Moderate Severe Indeterminate
Tubules description	Tubules description: Desription of tubular changes, e.g. hyalin droplet change, acute epithelial damage, cytoplasmic vacuolation, sloughing of cells, loss of brush border.
Interstitium	Interstitium: Interstitial changes, especially semiquantitative or quantitative assessment of interstitial fibrosis.
No abnormality detected	No abnormality detected: A statement that no abnormality was detected in the renal interstitium.
Quantification of interstitial fibrosis	Quantification of interstitial fibrosis: Quantification of interstitial fibrosis by image analysis methods.
Technique	Technique: Technique used to quantify fibrosis. Kodet tekst Sirius red unpolarized Sirius red polarized Collagen III immunohistochemistry Fri eller kodet tekst
Percentage interstitial fibrosis	Percentage interstitial fibrosis: Percentage of the renal cortical tissue involved by fibrosis. Enheter: %
Multimedia representation of image analysis	Multimedia representation of image analysis: Images, graphs and tables from automatic image analysis of interstitial fibrosis.
Cortical area with fibrosis estimated	Cortical area with fibrosis estimated: Visual quantification of interstitial fibrosis; The fibrosis percentage is the percentage of abnormal cortical tissue with fibrosis. <=0 %
Fibrous tissue estimated	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. Enheter: %
Interstitium description	Interstitium description: Description of interstitial changes, e.g. edema, inflammatory cells, deposits.
Vasculature	Vasculature: Changes affecting arteries, arterioles, venes and peritubular capillaries.
No abnormality detected	No abnormality detected: A statement that no abnormality was detected in the renal vasculature.
Number of arteries	Number of arteries: Number of arteries in a renal biopsy.
Arteriosclerosis	Arteriosclerosis: Amount of arteriosclerosis in the most affected vessel. Kodet tekst Not present/minimal Mild Moderate Severe Fri eller kodet tekst
Arteriolosclerosis	Arteriolosclerosis: Amount of arteriolosclerosis in the most affected vessel. Fri eller kodet tekst Kodet tekst Absent Present - nodular Present - circumferential
Vasculature description	Vasculature description: Description of vascular changes, e.g. vasculitis, venulitis. For description of severity of arteriosclerosis and arteriolosclerosis use coded text.
Amyloid	Amyloid: Findings related to amyloid deposition.
Amyloid not detected	Amyloid not detected: A statement that no amyloid deposition was detected.
Multimedia representation	Multimedia representation: Images from lesions could be attached here.
Pathological interpretation	Pathological interpretation: Single word, phrase of brief description representing the interpretation of the histopathology finding. A coded term is preferred.
Test representation	Test representation: Rich text or other multimedia representation of this particular result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent.
Description	Description: A narrative description of the group of histopathology findings.
Container 2	Container 2: Findings and interpretation of histopathology (anatomic pathology) tests performed on tissues and body fluids.
Macroscopic findings	Macroscopic findings: A group of findings within the histopathology examination. The Runtime name constraint allows identification of the type of histopathology examination performed.
Histopathology finding	Histopathology finding: Details of an individual histopathology finding, often related to a specific anatomical location or specimen.
Tissue available	Tissue available: True if the tissue is available for examination.
Specimen	Specimen: To record details of a laboratory specimen.
Specimen type	Specimen type: The type of specimen to be collected e.g venous blood, prostatic biopsy. Optional[{fhir_mapping=Specimen.type}]
Datetime collected	Datetime collected: The date and time that collection has been ordered to take place or has taken place.
Sampling conditions	Sampling conditions: Any conditions to be met before the sample should be taken. e.g. fasting, 'full bladder', 'sterile field' or any special instructions on the handling or immediate processing of the sample e.g. centrifuge on receipt. Can also be used to document any known deviations from collection or handling instructions e.g patient was not fasted.
Fysiske egenskaper til et objekt	Fysiske egenskaper til et objekt: For registrering av de fysiske egenskaper til et objekt som en kroppsdel eller en lesjon.
Navn på det fysiske objektet	Navn på det fysiske objektet: Den aktuelle gjenstanden. Kan være en kroppsdel, enhet eller prøve. Needle core biopsy
Dimensjon	Dimensjon: Dimensjonene til objektet.
Lengde	Lengde: Lengden til objektet.
Specimen container	Specimen container: Details of a specimen container. This is often integral to workflow and reporting of pathology specimens, particularly anatomical and histological pathology specimens.
Container additive	Container additive: Any special fixative or transport medium requirements. Annotations Notes.Example: McDowell
Description	Description: A narrative description of the group of histopathology findings.
Microscopic findings	Microscopic findings: A group of findings within the histopathology examination. The Runtime name constraint allows identification of the type of histopathology examination performed.
Semitynnsnitt	Semitynnsnitt: Details of an individual histopathology finding, often related to a specific anatomical location or specimen.
Tissue available	Tissue available: True if the tissue is available for examination.
Description	Description: A narrative description of the histopathology finding.
Microscopy renal biopsy non neoplastic	Microscopy renal biopsy non neoplastic: Microscopic findings related to a non-neoplastic renal biopsy
Renal biopsy overall description	Renal biopsy overall description: Describes tissue types in the renal biopsy specimen.
Cortex	Cortex: Cortical tissue present, alternatively core length with cortical tissue, alternatively proportion of cortical tissue in relation to the core with renal tissue. Kodet tekst Present Absent Indeterminate KvantitetEnheter: mm Proporsjon Prosent
Medulla	Medulla: Medullary tissue present, alternatively core length with medullary tissue, alternatively proportion of medullary tissue in relation to the core with renal tissue. Kodet tekst Present Absent Indeterminate KvantitetEnheter: mm Proporsjon Prosent
Renale capsule	Renale capsule: A statement whether the renal capsule is present.
Other tissue elements	Other tissue elements: Description of other tissue elements, e.g. muscle tissue. Kodet tekst Sceletal muscle and/or fat tissue and/or connective tissue Renal pelvis mucosa Fri eller kodet tekst
Glomeruli	Glomeruli: Description of glomerular changes.
Glomeruli	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	Scorable glomeruli: The number of glomeruli judged as adequate for scoring by the reporting pathologist.
Glomeruli solely with necrosis	Glomeruli solely with necrosis: The number of glomeruli showing fibrinoid necrosis without crescent formation.
Glomeruli with crescents	Glomeruli with crescents: The number of glomeruli showing cellular or fibrocellular crescents.
Glomeruli with ischemic changes	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 adhesions	Glomeruli with adhesions: The number of glomeruli showing coneective tissue connections between the tuft and Bowman's capsule without overt sclerosis.
Glomeruli with segmental sclerosis	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	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	Normal glomeruli: The number of glomeruli which appear normal without major changes.
Mesangium	Mesangium: Description of mesangial changes.
No abnormality detected	No abnormality detected: Statement that no abnormality was detected on examination of the mesangial areas.
Details of the mesangium	Details of the mesangium: A narrative description of mesangial changes.
Mesangial matrix increase	Mesangial matrix increase: Visual assessment of the amount of mesangial matrix. Kodet tekst Absent Slight Moderate Severe Equivocal Indeterminate Boolsk
Mesangial hypercellularity	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. Kodet tekst Absent Slight Moderate Severe Equivocal Indeterminate Boolsk
Mesangial nodularity	Mesangial nodularity: A visual assessment of the presence of acellular PAS positive mesangial nodules. Kodet tekst Absent Present Equivocal Indeterminate Boolsk
Capillaries	Capillaries: Description of glomerular capillary changes.
No abnormality detected	No abnormality detected: Statement that no abnormality was detected on examination of the glomerular capillaries.
Details of glomerular capillaries	Details of glomerular capillaries: A narrative description of glomerular capillary changes.
Capillary wall thickening	Capillary wall thickening: A visual assessment of the capillary wall thickness. Kodet tekst Absent Focal Diffuse Segmental Global Equivocal Indeterminate Boolsk
Capillary wall duplication	Capillary wall duplication: A visual assessment of the presence of capillary wall duplication. Boolsk Kodet tekst Absent Focal Diffuse Segmental Global Equivocal Indeterminate
Mesangial cell interposition	Mesangial cell interposition: A visual assesment of the presence of interposed cells in the capillary periphery. Fri eller kodet tekst Kodet tekst Present Absent Equivocal Indeterminate
Capillary lumen	Capillary lumen: Description of changes in the capillary lumens.
Thrombi	Thrombi: Findings related to intracapillary thrombi.
Thrombi	Thrombi: Visual assessment of intracapillary thrombi. Kodet tekst Absent Focal Diffuse Segmental Global Equivocal Indeterminate Fri eller kodet tekst
Thrombus type	Thrombus type: Type of intracapillary thrombi. Hyalin Fibrin
Endocapillary hypercellularity	Endocapillary hypercellularity: Findings related to endocapillary cellularity.
Endocapillary hypercellularity	Endocapillary hypercellularity: Visual assessment of endocapillary hypercellularity. Kodet tekst Absent Focal Diffuse Segmental Global Equivocal Indeterminate Boolsk
Cell type	Cell type: Composition of intracapillary cells. Fri eller kodet tekst Kodet tekst Endothelial cells Macrophages Neutrophil granulocytes Lymphocytes Atypical cells
Podocytes	Podocytes: Description of podocyte changes.
No abnormality detected	No abnormality detected: Statement that no abnormality was detected on examination of podocytes.
Details of podocytes	Details of podocytes: A narrative description of podocyte changes.
Hypertrophy	Hypertrophy: Enlarged podocytes often with amphophil cytoplasm. Kodet tekst Absent Slight Moderate Severe Equivocal Indeterminate Fri eller kodet tekst Boolsk
Bi- or multinucleated podocytes	Bi- or multinucleated podocytes: Podocytes with 2 or more nuclei. Absent Present Equivocal Indeterminate Antatt verdi: Absent
Resorption droplets	Resorption droplets: Podocytes with PAS positive resorption droplets. Absent Singular cells Numerous cells Equivocal Indeterminate
Pseudocysts	Pseudocysts: Podocytes with pseudocysts. Absent Singular Numerous Equivocal Indeterminate
Description of glomeruli	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).
Tubules	Tubules: Description of tubular changes.
No abnormality detected	No abnormality detected: A statement that no abnormality was detected in renal tubules.
Tubular epithelial cell changes	Tubular epithelial cell changes: Description of tubular epithelial cell changes. Multiple choices possible. Hyaline droplet change Fine vacuolization Coarse vacuolization Fatty change Giant mitochondria
Casts in tubules	Casts in tubules: Choose the type of casts present in tubuli. Multiple choices possible. Tamm Horsfall protein Hyaline casts Granular casts Detached cells Red blood cells Granulocytes Mixed casts Pigmented casts Myeloma casts Crystals
Tubular casts	Tubular casts: Structured report of kind of tubular casts present.
Tamm Horsfall protein	Tamm Horsfall protein: Presence of intratubular Tamm Horsfall protein.
Hyaline casts	Hyaline casts: Presence of hyalin casts in tubular lumen.
Granular casts	Granular casts: Presence of granular casts in tubular lumen.
Detached cells	Detached cells: Detached cells, commonly epithelial cells, present in the tubular lumen.
Red blood cells	Red blood cells: Collections of red blood cells or red blood cell casts present in tubular lumen.
Granulocytes	Granulocytes: Presence of neutrophil granulocytes in tubular lumen.
Mixed casts	Mixed casts: Casts consisting of more than one component.
Pigmented casts	Pigmented casts: Discolorated casts e.g. due to hemoglobin, myoglobin, drug pigments, bilirubin, melanin.
Myeloma casts	Myeloma casts: Characteristic myeloma casts, often surrounded by reactive tubular epithelial cells. or multinucleated cells, present in tubular lumen.
Crystals	Crystals: Crystals present in tubular lumen.
Tubular atrophy	Tubular atrophy: Semiquantitative or quantitative assessment of tubular atrophy.
Tubular atrophy semiquantitative	Tubular atrophy semiquantitative: Semiquantitative visual assessment of tubular atrophy. Absent Slight Moderate Severe Indeterminate
Tubules description	Tubules description: Desription of tubular changes, e.g. hyalin droplet change, acute epithelial damage, cytoplasmic vacuolation, sloughing of cells, loss of brush border.
Interstitium	Interstitium: Interstitial changes, especially semiquantitative or quantitative assessment of interstitial fibrosis.
No abnormality detected	No abnormality detected: A statement that no abnormality was detected in the renal interstitium.
Quantification of interstitial fibrosis	Quantification of interstitial fibrosis: Quantification of interstitial fibrosis by image analysis methods.
Technique	Technique: Technique used to quantify fibrosis. Kodet tekst Sirius red unpolarized Sirius red polarized Collagen III immunohistochemistry Fri eller kodet tekst
Percentage interstitial fibrosis	Percentage interstitial fibrosis: Percentage of the renal cortical tissue involved by fibrosis. Enheter: %
Multimedia representation of image analysis	Multimedia representation of image analysis: Images, graphs and tables from automatic image analysis of interstitial fibrosis.
Cortical area with fibrosis estimated	Cortical area with fibrosis estimated: Visual quantification of interstitial fibrosis; The fibrosis percentage is the percentage of abnormal cortical tissue with fibrosis. <=0 %
Fibrous tissue estimated	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. Enheter: %
Interstitium description	Interstitium description: Description of interstitial changes, e.g. edema, inflammatory cells, deposits.
Vasculature	Vasculature: Changes affecting arteries, arterioles, venes and peritubular capillaries.
No abnormality detected	No abnormality detected: A statement that no abnormality was detected in the renal vasculature.
Number of arteries	Number of arteries: Number of arteries in a renal biopsy.
Arteriosclerosis	Arteriosclerosis: Amount of arteriosclerosis in the most affected vessel. Kodet tekst Not present/minimal Mild Moderate Severe Fri eller kodet tekst
Arteriolosclerosis	Arteriolosclerosis: Amount of arteriolosclerosis in the most affected vessel. Fri eller kodet tekst Kodet tekst Absent Present - nodular Present - circumferential
Vasculature description	Vasculature description: Description of vascular changes, e.g. vasculitis, venulitis. For description of severity of arteriosclerosis and arteriolosclerosis use coded text.
Amyloid	Amyloid: Findings related to amyloid deposition.
Amyloid not detected	Amyloid not detected: A statement that no amyloid deposition was detected.
Multimedia representation	Multimedia representation: Images from lesions could be attached here.
Pathological interpretation	Pathological interpretation: Single word, phrase of brief description representing the interpretation of the histopathology finding. A coded term is preferred.
Test representation	Test representation: Rich text or other multimedia representation of this particular result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent.
Elektronmikroskopi	Elektronmikroskopi: Details of an individual histopathology finding, often related to a specific anatomical location or specimen.
Tissue available	Tissue available: True if the tissue is available for examination.
Description	Description: A narrative description of the histopathology finding. Annotations Notes.Reviewers Note: Det er enda ikke laget et strukturert CLUSTER for dette så det må være fritekst for nå.
Pathological interpretation	Pathological interpretation: Single word, phrase of brief description representing the interpretation of the histopathology finding. A coded term is preferred.
Test representation	Test representation: Rich text or other multimedia representation of this particular result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent.
Description	Description: A narrative description of the group of histopathology findings.
Vurdering	Vurdering: Konsis, tekstlig tolkning av laboratoriesvaret, satt i en klinisk sammenheng.
Diagnose fritekst	Diagnose fritekst: Enkeltord, frase eller kort beskrivelse som beskriver teksten i "Konklusjon". Koding med en terminologi foretrekkes, der det er mulig.
Diagnose terminologi	Diagnose terminologi: Enkeltord, frase eller kort beskrivelse som beskriver teksten i "Konklusjon". Koding med en terminologi foretrekkes, der det er mulig.
Kommentar	Kommentar: Tekstlig tilleggsinformasjon som ikke er registrert i andre felt.
Protocol	Protocol: *@ internal @(en)
SvarID	SvarID: Lokal ID som er gitt til analysesvaret av laboratoriesystemet (LIS). Annotations Notes.Question: Is this where the Biopsy number is recorded? Or should it be recorded in an overall the laboratory specimen identifier in an overall instance of the specimen cluster

TEMPLATE Kidney biopsy use case 1 (Kidney biopsy use case 1)

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