Changes at the glomerular tip: a feature of membranous nephropathy and other disorders associated with proteinuria.

Renal biopsies and post-mortem kidneys were examined for segmental lesions at glomerular tips, consisting of adhesion of the tuft to Bowman's capsule with an area of intra-capillary foam cells or hyaline material or sclerosed material. Of 72 consecutive renal biopsies showing membranous nephropathy, 46 (64 per cent) had tip changes. Such changes were correlated with the presence of acute tubular damage and with later stages of the nephropathy, but otherwise seemed unrelated to any particular clinical or pathological feature. Fourteen other patients were identified whose renal biopsies showed tip changes in glomeruli that had segmental or global mesangial hypercellularity not of a well-recognized type such as IgA nephropathy. These patients had persistent proteinuria unresponsive to steroids. Tip changes were also seen in several miscellaneous conditions including IgA nephropathy and diabetic glomerulosclerosis. These findings demonstrate that tip changes are seen in many disorders of the kidney associated with proteinuria and represent a previously unrecognized common response of the glomerulus to some insult, the glomerular tip lesion, as originally defined, is distinguished by the apparent normality of tufts except for the tip changes and can be regarded as presumed minimal change nephropathy plus tip changes and when tip changes are seen, the most important factor determining the prognosis is the condition of the rest of the glomerular tuft.