#2281 SEM for the diagnosis of glomerular diseases (amyloidosis, minimal change, thin membrane, IgA, membranoproliferative and diabetic nephropathy)
Authors: Viggiano Davide , Reverchon Ernesto , Reverchon Giorgio , Mariarosa Scognamiglio , Borriello Gianmarco , Gigliotti Andrea , Gigliotti Giuseppe , Nigro Michelangelo 
Published: May 2024

Abstract

Background and Aims
Treating renal diseases often requires ultrastructural details to establish or confirm diagnosis. Ultrastructural information that is not evidenced by optical microscopy includes, e.g., the podocyte foot processes effacement, thinning or alteration of basement membrane, presence of fibrils, Fabri's intracellular inclusions and subepithelial vs. subendothelial of deposits. Unfortunately, transmission electron microscopy (TEM), required to achieve the required resolution, has high costs, and is time-consuming. Here, we report our experience with scanning electron microscopy (SEM) on paraffin sections from standard pathology sections.

Method
We have retrospectively reanalyzed paraffin sections from renal biopsies of 50 patients with a diagnosis of IgAN, minimal change, diabetes, and amyloidosis. The paraffin sections were available and processed according to standard procedures (fixation, paraffin embedding), with a thickness of 3-4 µm. Sections were deparaffinized, stained with PASM (periodic acid Shiff + methenamine), mounted in aqueous mounting medium and imaged with 40x and 60x objectives. Sections were then unmounted, washed to remove glycerol, dehydrated in absolute alcohol, and air-dried. Finally, they were gold coated (“sputtering”) and analyzed in a scanning electron microscope (Zeiss).

Results
For the interpretation of SEM images, correlative analysis has been used, imaging precisely the same region of the section using standard optical microscopy and SEM. SEM can quickly identify the typical morphology of podocyte foot processes (Fig. 1A) and the podocyte effacement in minimal change disease (Fig. 1B). SEM can also easily allow the measurement of the thickness of the basement membrane of glomerular capillary walls (Fig. 1C-E) and its thinning in case of thin membrane disease (Fig. 1D) or its increased thickness in the case of diabetes (Fig. 1E). Amyloid fibrils (Fig. 1F) can also be identified in the capillary walls, confirming the diagnosis of amyloidosis Congo-red positive (Fig. 1G). The high resolution of the technique allows us to identify with high reliability the small ruptures of the capillary walls in IgA and membranoproliferative nephritis, with extravasation of erythrocytes and fibrin cloths (Fig. 1H). Mitochondria are well-demarcated, particularly in proximal tubule cells, and often, mitochondrial cristae are visible in samples with adequate fixation (Fig. 1I). Interstitial edema and fibrosis are evident in SEM microscopy (Fig. 1L). At very high magnification, in histological preparations with exceptional fixation, the filtration pores of endothelial cells could be observed (partially visible in Fig. 1E), as well as details such as the brush border of the tubular epithelial cells. The interpretation of the images is not always straightforward as it also requires knowledge of the artifacts induced by the fixation, processing, and inclusion of paraffin, such as, for example, the intracytoplasmic cellular structures containing lipids of the intratubular “foam cells” appear empty. For a correct interpretation of the SEM images, however, the recognition of the nuclei is essential because the chromatin is condensed into clods, especially around the periphery, and inside, some areas appear empty.

Conclusion
Scanning electron microscopy (SEM) is a powerful tool for the study of nephrological diseases, as it allows you to examine microscopic details at the nanometric scale (not detectable in optical microscopy), providing valuable information for diagnosis, understanding, and management of the disease, the possibility of carrying out Correlative Microscopy. Given the relatively simple and fast preparation of the samples to be examined, the low costs of execution, and the possibility of archiving the preparation in the histotheque for a possible revision of the case, this leads us to think that this method could be considered a valid alternative to transmission electron microscopy (TEM).