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Diagnosis: First biopsy: Diabetic nephropathy (pre-existent of the donor) and acute tubular necrosis

Second biopsy: Diabetic nephropathy with crescents

It is not easy to know with certainty whether in the present case there is one disease (a form of diabetic nephropathy) or there are a proliferative GN (with crescents) superimposed upon an underlying diabetic nephropathy. Anti-GBM antibodies and ANCAs tests were negative. We are left with the notion that there is superimposed proliferative GN that we cannot easily explain.

There was no evidence, clinically or via renal biopsy or immunofluorescence of a resolving post-infectious GN.

Although renal pathologists understand what a crescent is and how to diagnosis it, it is likely that occasionally experts will disagree what a crescent is and whether it is present in a specific biopsy. After consideration of all definitions of crescents and case review, we interpreted that this renal biopsy did show crescent formation. Although still somewhat arbitrary, most authors now require approximately 50% of the glomeruli to harbor crescents to diagnose "crescentic GN". In the present case crescents were found in 5 of 35 non-sclerosede glomeruli (14%). Thus, in this patient, we diagnosed "diabetic nephropathy with crescents" insted "crescentic GN".

In a review on crescentic GN (Jennette JC: Kidney Int 2003;63:1164-1177 [PubMed link]) the author describe 648 renal biopsy specimens with diabetic glomerulosclerosis and no other known disease, 3.2% had some degree of crescent formation. When crescents were present, on average only 20% of the glomeruli had crescents. Only 2 patients had more than 50% crescents. "Thus, crescents in diabetic nephropathy are not at all common, but no unheard of. Their true meaning (with regards to diagnosis, prognosis, and therapy) remain unclear" (Silva F, Dalton RR. Case 1 - Diffuse Diabetic Glomerulosclerosis (With Early Nodular Diabetic Glomerulosclerosis) with Proliferative GN (Superimposed Cellular Crescents). In: 2006 USCAP Annual Meeting, Renal Pathology Specialty Conference: www.uscap.org/ Consulted: July 26, 2007).

See the chapter The kidney in diabetes mellitus... (English version).

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Bibliography

• Huang F, Yang Q, Chen L, Tang S, Liu W, Yu X. Renal pathological change in patients with type 2 diabetes is not always diabetic nephropathy: a report of 52 cases. Clin Nephrol. 2007;67:293-7. [PubMed link]
• Silva F, Dalton RR. Case 1 - Diffuse Diabetic Glomerulosclerosis (With Early Nodular Diabetic Glomerulosclerosis) with Proliferative GN (Superimposed Cellular Crescents). In: 2006 USCAP Annual Meeting, Renal Pathology Specialty Conference: www.uscap.org/ Consulted: July 26, 2007.
• Molitch ME, DeFronzo RA, Franz MJ, Keane WF, Mogensen CE, Parving HH, Steffes MW; American Diabetes Association. Nephropathy in diabetes. Diabetes Care. 2004;27 Suppl 1:S79-83. [PubMed link] [Free full text]
• Jennette JC. Rapidly progressive crescentic glomerulonephritis. Kidney Int. 2003;63:1164-77. [PubMed link]
• Kitazawa M, Tomosugi N, Ishii T, Hotta F, Nishizawa M, Itou T, Nakano S, Kigoshi T, Ishikawa I, Uchida K. Rapidly progressive glomerulonephritis concomitant with diabetic nephropathy. Intern Med. 1997;36:906-11. [PubMed link] [Free full text]
  

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