Light Microscopy

Microscopically, there is tubular atrophy with associated interstitial fibro-sis, with areas of tubular dropout in more severe cases. Foci of thinned dilated tubules containing cast material may be seen (thyroidization), particularly in the outer cortex. Tubules focally are ruptured, and Tamm-Horsfall protein with other intraluminal contents is in extratubular locations. Mononuclear inflammatory cells including lymphocytes, histio-cytes, and plasma cells are throughout the interstitium in large numbers (Figs. 14.1 and 14.2); lymphoid follicles may be observed. If active infection

Figure 14.2. Lymphocytes are in the fibrotic interstitium and in walls of some atrophied tubules (PAS stain).

is still present, neutrophils and a small number of eosinophils may also be found. The calyces and pelvis disclose mononuclear leukocytes, fibrosis, and hypertrophy of the smooth muscle; the overlying transitional epithelium may be hyperplastic or display glandular or squamous metaplasia. Renal arteries often have intimal fibrosis and muscular hypertrophy, while glomeruli show ischemic collapse and periglomerular fibrosis. Glomeruli may have Tamm-Horsfall protein in Bowman's space. In severe reflux nephropathy, there is hypertrophy of the glomeruli and tubules in the nonscarred parenchyma; there is sharp demarcation between the scarred and preserved parenchyma. Enlarged glomeruli may also demonstrate focal and segmental glomerulosclerosis. Some investigators have reported that in nonscarred areas, glomeruli with elongated capillaries, adhesions, and podocyte detachment were associated with a poorer prognosis (5).

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