J. Comp. Path. 2021, Vol. 187, 52e62 Available online at www.sciencedirect.

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SPONTANEOUSLY ARISING DISEASE

Renal Crest Proliferative Lesions in Cats with

Chronic Kidney Disease
Joanna D White*,
Katrina L Bosward*, Jacqueline M Norris*, Richard Malik†,
Scott A Lindsay‡ and Paul J Canfield*
* Sydney School of Veterinary Science, University of Sydney, † Centre for Veterinary Education, Veterinary Science Conference
Centre B22, University of Sydney, Sydney, New South Wales and ‡ School of Animal and Veterinary Sciences, Faculty of
Science, University of Adelaide, Adelaide, South Australia, Australia

Summary
In a histopathological study of the renal crest (RC) of kidneys of cats with chronic kidney disease (CKD), 58/90
(64%) had epithelial proliferation. Of these, 33 cats had hyperplasia of the collecting duct (CD) epithelium
(CDH) alone, eight had hyperplasia of the urothelium covering the RC (RCUH), of which one had concurrent
abaxial renal pelvic urothelial hyperplasia (UH), and eight had both CDH and RCUH. CDH or RCUH were
present in five cats with marked dysplasia of the CD epithelium (CDD) and four cats with invasive carcinomas,
which also had epithelial dysplasia. All nine cats with marked dysplasia or neoplasia of the RC also had sub-
stantially altered RC contours due to focal haemorrhage, papillary necrosis or fibrosis. Three of the carcinomas
had a strong desmoplastic response. In control cats, both urothelial (RC and renal pelvis) and tubular (CD and
distal tubular) cells were immunopositive for cytokeratin (CK; AE1/AE3), tubular epithelial cells were positive
for vimentin (Vim) and aquaporin 2 (Aq2), while urothelial cells were positive for p63. PAX8 immunolabel-
ling was difficult to validate. CD and UH labelling was similar to control tissue. While urothelial dysplasia had
the same immunolabelling pattern as UH and control tissue, CDD was generally immunonegative for Aq2. As
immunolabelling of the four carcinomas did not distinguish between tubular and urothelial origin, with three
positive for both Vim and p63, all were broadly designated as RC carcinomas. Overall, proliferative epithelial
lesions are common in cats with CKD and form a continuum from simple hyperplasia to neoplasia of the ur-
othelium or CD of the RC.

Ó 2021 Elsevier Ltd. All rights reserved.

Keywords: chronic kidney disease; collecting duct proliferation; feline; urothelial proliferation

Introduction those affecting the single renal papilla (renal crest;

Chronic kidney disease (CKD) is common in older
cats and chronic tubulointerstitial nephritis (TIN) is
the most common histopathological process (Lucke,
1968; DiBartola et al, 1987; Lulich et al, 1992; Elliott
and Barber, 1998; McLeland et al, 2015; Brown
et al, 2016). Microscopic descriptions of CKD in do-
mestic cats have focussed on glomerular, corticome-
dullary tubular and interstitial changes rather than
RC). The RC is the rounded projection at the base
of the renal pyramid of the inner medulla that com-
municates with the renal pelvis (RP). This anatom-
ical region is not considered to be a common site for
histological change, except for three discrete disease
processes, namely pyelonephritis (Parry, 2005),
papillary necrosis (Lucke, 1968; DiBartola et al,
1987; Wolf et al, 1991; Stewart et al, 2003) and medul-
lary amyloidosis (Boyce et al, 1984).

Correspondence to: JD White (e-mail: jwhite@sashvets.com).

0021-9975/$ - see front matter Ó 2021 Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.jcpa.2021.07.002
 Renal Crest Lesions in Cats with Chronic Kidney Disease
In contrast, proliferative lesions of the renal
papilla, ranging from hyperplasia to neoplasia, have
been well documented in humans with analgesic ne-
phropathy (Blohme and Johansson, 1981) and in lab-
oratory animals (Bokelman et al, 1971; Frazier et al,
2012). In non-domestic felids, hyperplasia and
dysplasia of the papillary ducts and urothelium lining
the RC have been associated with papillary necrosis
in CKD (Wolf et al, 1991), but in domestic cats the
only reported proliferative lesions of the RC associ-
ated with CKD have been simple hyperplasia of the
papillary ducts and urothelium lining the RC
(Lourenço et al, 2020) and transitional cell carcinoma
(TCC; renal urothelial carcinoma) originating in the
RP and invading the RC (Hanzlicek et al, 2012).
The aim of this study was to describe the frequency
and appearance of proliferative lesions of the RC in
cats with CKD.
Materials and Methods
Cohort of Cats, Necropsy and Histology
A large cohort of cats with CKD were recruited and
managed by the first author (White et al, 2006). To
be included in the study, cats were required to have
had a history and clinical signs consistent with CKD
and azotaemia, and inadequately concentrated urine
(when measured). Cats were euthanized due to the
severity of their clinically detected CKD or co-
morbidities and necropsies were performed with
owners’ consent. CKD was confirmed by histopatho-
logical examination of the kidneys. Of the 90 cats
included in the study, 40 were female, 47 were male
and for three the gender was not recorded. All cats
had been neutered and they ranged in age from 2 to
21 years, with a median of 13 years and an interquar-
tile range of 10e16 years. Multiple renal sections
incorporating all layers of both kidneys (where
possible) were selected for microscopic examination.
Formalin-fixed, paraffin-embedded tissue was
sectioned at 5 mm for haematoxylin and eosin (HE)
staining or at 2 mm for Masson’s trichrome and peri-
odic acideSchiff (PAS) staining. All stained sections
were examined by the first author and at least two
of KLB, SAL or PJC. Where there was initial
disagreement on the classification of RC proliferative
lesions, additional veterinary pathologists (see Ac-
knowledgments) were asked to review the lesions
and a consensus diagnosis was obtained.
Definition of the Examined Renal Crest
For examination purposes, the RC was designated as
the region where merged renal papillae connect with
the RP. This included the apex of the renal pyramid
53
of the medulla, composed of mainly inner medullary
collecting ducts (CDs) that eventually merge to
form terminal larger CDs (papillary ducts or ducts
of Bellini). Histopathological sections of RC always
included inner medullary interstitium and CDs, lined
by either cuboidal or low columnar epithelium, to the
point where they connected with the 2e3 cell layered
urothelium (renal transitional epithelium) of the RC
(RCU). Included in RC sections were the opposing
urothelium and underlying lamina propria of the
RP, and sometimes the fat, major vessels and nerves
within the renal sinus (the cavity that includes RP,
fat and major vessels). The renal hilus, where the ure-
ter entered, was occasionally present.
Definitions Used for Proliferative Lesions of the Renal Crest
Due to the similarity of the renal papillary structure
between rats, mice and cats (all unipapillate kidneys)
(Frazier et al, 2012), definitions for proliferative
changes to the RC were based primarily on rodent
guidelines (Frazier et al, 2012; Seely and Brix, 2014)
rather than on human guidelines. The term collecting
duct hyperplasia (CDH) was used when most ducts
were lined by a single layer of epithelial cells, were
increased in number and sometimes in size, and
were showing little nuclear pleomorphism but vari-
able cytoplasmic basophilia, and rare mitoses. The
term collecting duct dysplasia (CDD) was used
when most ducts were characterized by an increased
number of epithelial cells, usually in 2e3 layers,
with variable degrees of anisocytosis and nuclear pleo-
morphism (cellular atypia, including karyomegaly)
and occasional mitoses. Ductal expansion was identi-
fied by flattening of surrounding stromal fibroblasts.
RC urothelial hyperplasia (RCUH) was defined as
hyperplasia of the urothelium of the RC, characterized
by diffuse thickening or variably sized outgrowths with
clear spaces among the cells. Cellular features included
hypertrophy and cytoplasmic and nuclear basophilia,
but rare mitoses. The term atypical hyperplasia or
dysplasia of the RC urothelium is not used in rodent
studies, but if cellular atypia is marked, mitoses com-
mon and no invasion is obvious, the changes are
referred to as carcinoma in situ (Frazier et al, 2012;
Seely and Brix, 2014). However, the term RC urothe-
lial dysplasia (RCUD) was preferred to carcinoma in
situ in this study to describe a broad spectrum of
mild, moderate and marked cellular atypia.
A diagnosis of CD or renal TCC required evidence
of invasion of the basement membrane into surround-
ing stroma, usually with necrosis and haemorrhage.
Marked cellular atypia (especially karyomegaly)
and mitoses (both normal and abnormal) were com-
mon.
54 J D White et al

Immunohistochemistry tubular loss, interstitial fibrosis and inflammation

All samples with neoplasia or marked dysplasia, repre-
sentative cases of hyperplasia and a normal feline kidney
(control tissue) were selected for immunohistochemistry
(IHC) studies. Five antibodies directed against aqua-
porin 2 (Aq2), cytokeratin (CK; AE1/AE3), p63,
PAX8 and vimentin (Vim) were used (Table 1).
Routine IHC staining of 4 mm sections using the
DakoCytomation Autostainer (Agilent, Santa Clara,
California, USA) involved endogenous peroxidase
blocking (3% H2O2, 15 min) and antigen retrieval
(Dako Proteinase K Ready-to-Use, S3020 [Agilent],
10 min; or heat induced epitope retrieval), prior to in-
cubation with the primary antibody for 60 min at
room temperature (Table 1). Negative control slides
omitted the primary antibody or were labelled with
an irrelevant antibody (isotype controls raised in the
same species as the primary antibody for all mono-
clonal markers were used). Binding was detected us-
ing a commercial peroxidase system (Dako REAL
EnVision Detection System, Peroxidase/DAB+,
Rabbit/Mouse, K5007 [Agilent], 30 min).
IHC labelling by the primary antibodies was
scored for reactivity and intensity based on a modifi-
cation of the system of Ramos-Vara et al (2017). Reac-
tivity was based on the percentage of cells labelled
(<5% ¼ negative; 6e25%; 26e50%; >50%), while
intensity of labelling was designated subjectively as
mild, moderate or marked.
Results
Study Population
All 90 cats had histological evidence of TIN of the cor-
tex and medulla characterized by variable degrees of
Table 1
Immunohistochemical protocols for labelling of renal crest elements
involving primarily mononuclear infiltrates of lym-
phocytes, plasma cells and macrophages, occasional
eosinophils and, to a lesser extent, neutrophils.
Glomerular sclerosis was present within areas of
cortical interstitial fibrosis, and both changes were
confirmed by staining with Masson’s trichrome. In
addition to TIN, a primary glomerulopathy was sus-
pected in 15 cats on the basis of thickened or irregular
basement membranes detected by PAS and Masson’s
trichrome staining, although not confirmed with
immunofluorescence or electron microscopy. Medul-
lary interstitial amyloidosis was detected in four cats
and renal lymphoma in four, while polycystic disease,
focal cortical granulomas and vasculitis were each
observed in a single cat.
Proliferative Lesions of the Renal Crest and Pelvis
Hyperplasia. Hyperplasia was present in 58 cats
including five with marked dysplasia and four with
carcinoma (Table 2).
CDH alone, most obvious in the inner medulla, was
identified in 33 cats, and consisted of cuboidal to
columnar cells, typically in one layer, with basophilic
cytoplasm and oval to round, hyperchromatic nuclei
(Fig. 1A). Mitoses were rare. Urothelial hyperplasia
of the RC, the RP, or both, was present in eight
cats. Concurrent CDH and RCUH were present in
an additional eight cats. Urothelial hyperplasia was
typically characterized by discrete multifocal thick-
ening, although some cases had diffuse, even thick-
ening of the epithelium with up to six or seven
layers of RC urothelium (Fig. 1A). Discrete thicken-
ings, which were more common in RC urothelium,

Antibody Antibody source Antibody details (clone) Dilution Antigenic retrieval/block* Labelling site

Aquaporin 2 Merck, Darmstadt, Polyclonal rabbit anti- 1:50 HIER, pH9/none Cytoplasmic
Germany (AB3066) rat aquaporin 2 (C-
terminal)
Cytokeratin Dako, Glostrup, Monoclonal mouse, anti- 1:100 HIER, pH9/none Cytoplasmic
Denmark (M3515) human cytokeratin
(AE1/AE3)
p63 BioCare Medical, Monoclonal mouse, anti- 1:100 HIER, pH9/none Nuclear
Pacheco, California, p63 (BC4A4)
USA (CM163)
PAX8 Abcam, Melbourne, Monoclonal mouse, anti- 1:100 HIER, pH9/10 min Nuclear
Australia (ab124445) PAX8 (BC12)
Vimentin Dako (M0725) Monoclonal mouse, anti- 1:200 HIER, pH9/none Cytoplasmic
porcine vimentin (V9)

HIER, heat-induced epitope retrieval.

*
Non-specific protein binding was minimized for the anti-PAX8 antibody by incubation with a commercial casein-based reagent for 10 min
(Blocking Solution Ready-to-Use; Candor Bioscience GmbH, Wangen, Germany).
 Renal Crest Lesions in Cats with Chronic Kidney Disease
Table 2
Renal crest proliferative lesions in 90 cats with chronic
kidney disease and concurrent lesions
Concurrent renal crest lesions
Proliferative No. of cats Papillary Papillary
category affected fibrosis necrosis
Hyperplasia 58* 21 1
Dysplasia 5** 4 1
Carcinoma 4*** 3 1
*
33 cats had collecting duct hyperplasia (CDH) alone, eight cats had
renal crest urothelial hyperplasia (RCUH) alone, eight cats had both
CDH and RCUH, while all nine cats with dysplasia and carcinoma
had areas of CDH and/or RCUH.
**
All five cats had accompanying areas of CDH and/or RCUH.
***
All four cats had accompanying areas of CDH and/or RCUH, and
collecting duct dysplasia (CDD).
were often polypoid in nature. Cells varied from flat-
tened to cuboidal with basophilic cytoplasm and oval,
hyperchromatic nuclei. Mitoses and apoptotic cells
characterized some of the hyperplastic areas. Hyper-
plastic lesions were occasionally infiltrated with small
numbers of neutrophils or lymphocytes.
Dysplasia. CDD was present in five cats primarily to-
wards the tip of the RC. Dysplasia was present bilat-
erally in the four cats for which both kidneys were
available for review. Microscopically, there were usu-
ally more than three layers of collecting duct epithe-
lium, which in some ducts almost obliterated the
lumen (Fig. 1B). Epithelial cells were cuboidal to
polygonal and had basophilic cytoplasm and large ve-
sicular but hyperchromatic nuclei with prominent
nucleoli. The cells had anisocytosis and nuclear pleo-
morphism, and there were scattered apoptotic cells
and mitoses. All cats with CDD had concurrent hy-
perplasia of CDs and RC uroepithelium. The
RCUH was marked and often multifocal. In two
Fig. 1. Hyperplasia and dysplasia, collecting ducts, kidney, cat. (A) Hyperplastic collecting ducts (arrows), composed of single layers of
columnar to cuboidal cells with basophilic cytoplasm, adjacent to area of renal crest hyperplasia. HE. (B) Dysplastic collecting
ducts (arrows) admixed with hyperplastic ducts (H). Some dysplastic ducts have obliterated lumina. HE.
55
cats, the RC urothelium was dysplastic with areas in
which nuclei were pleomorphic, hyperchromatic
and associated with prominent mitoses (Fig. 2A).
Concurrent abnormalities included a solidified blood
calculus attached near an area of RCUH in one cat
(Fig. 2B) and focal haemorrhage within the tip of
the RC in two cats.
Carcinoma. Four cats had invasive carcinomas
involving the RC. Neoplastic changes were present
bilaterally in two cats that had been first diagnosed
with CKD 1,072 and 1,819 days prior to euthanasia.
Palpable abnormalities were only noted ante mortem in
one cat with a unilateral RC carcinoma. At necropsy,
the affected kidney of this animal had an irregular,
firm, pale tan mass present at the level of the renal pel-
vic hilus. Kidneys from the two cats with bilateral
neoplasia were small and irregular.
Microscopically, neoplasia involved the medulla
and cortex in three of the four cats with carcinoma,
and extended to the capsule in one case. Neoplastic
cells in these cats were commonly present as solid,
elongate, sometimes papillary, clusters. The clusters
were variably cribriform, microcystic, cystic or con-
tained tubular formations (Fig. 3A). The cuboidal
to columnar cells had marked nuclear pleomorphism
with anisonucleolisis and basophilic cytoplasm. There
were scattered mitoses and apoptotic bodies. Desmo-
plastic stroma was prominent and contained scattered
lymphocytes and plasma cells (Fig. 3A). All three cats
had areas of concurrent epithelial hyperplasia and
dysplasia of CD and RC epithelium. Diffuse renal pel-
vic urothelial hyperplasia was present in one cat.
Medullary haemorrhage was a common feature and
often localized below surviving RC urothelium.
The fourth cat had marked neoplastic proliferation
and invasion of the RC urothelium (Fig. 3B). Associ-
ated with this was the formation of cystic spaces and
56 J D White et al

Fig. 2. Dysplasia, kidney, cat. (A) Early dysplasia of renal crest urothelium with proliferation and distortion (RCUD). Numerous
dysplastic (arrow) and hyperplastic collecting ducts (H). Small fibrin clot (FC) beneath renal crest urothelium. HE. (B) Concur-
rent lesions of large area of haemorrhage and fibrin deposition (Ha), mostly beneath hyperplastic renal crest urothelium (arrows),
but extending into pelvic cavity (PC). Gross blood calculus was present in this cat. HE.

apparent primitive tubule formation. The mainly
cuboidal cells displayed similar cytoplasmic and nu-
clear features to the other three cats. There was little
desmoplasia associated with invasion. Areas of CDH
and CDD were present and renal pelvic urothelial hy-
perplasia was mild and diffuse.
Immunohistochemical Results for Proliferative Lesions
Control Tissue. There was markedly intense immuno-
labelling of uroepithelium of the RC and RP and CD
and distal tubular epithelium (>50% of cells) for CK
(Table 3).
The cytoplasm of stromal tissue cells, CDs and
distal tubular epithelium was markedly immunopos-
itive (>50% of cells) for Vim. RC and renal pelvic
urothelium did not express Vim except for occa-
sional basal cells (<5% of cells). CD luminal sur-
faces were positive for Aq2 with moderate labelling
intensity in 26e50% of cells. RC and renal pelvic
urothelial cells were immunopositive with marked
intensity for nuclear p63 in 26e50% of cells. In gen-
eral, CD epithelium was immunopositive for nuclear
PAX8. Nuclear PAX8 staining of moderate intensity
was present in >50% of cells in CDs, but RC uroe-
pithelium was negative, except for occasional basal
cells.
Hyperplasia. CDH was immunopositive (>50% of
cells) for CK and positive (26e50% of cells) for
Vim. CDH staining for Aq2 was positive for 5e25%
of cells in two of the three cases examined (Fig. 4A).
CDH was immunonegative for p63 and PAX8,
although validation for PAX8 was uncertain because
of lack of expression in surrounding non-hyperplastic
CDs. RCUH was immunopositive (>50% of cells) for
CK, positive (>50% of cells) for p63 (Fig. 4B), but
negative for Aq2 and Vim (Fig. 4C).

Fig. 3. Carcinoma, kidney, cat. (A) Neoplastic cells in clusters. One large cluster with apparent lumen formation (arrow). Strongly desmo-
plastic stroma (D) contains scattered lymphocytes. HE. (B) Neoplastic cells invade surrounding stroma (arrows). Hyperplastic col-
lecting tubule (H). HE.
 Renal Crest Lesions in Cats with Chronic Kidney Disease 57

Table 3
Immunolabelling of renal crest proliferative lesions

Specimen Aquaporin 2 Cytokeratin (AE1/AE3) Vimentin PAX8 p63

R I R I R I R I R I

Normal renal crest 2+ 2+ 3+ 3+ 3+ 3+ 3+ 2+ 2+ 3+

(CD) (CD and RCU) (stroma and CD) (CD) (basal cells of RCU); -
(CD)
Carcinoma e e 3+ 3+ e e e e 2+ 3+
Carcinoma e e 3+ 3+ 3+ 3+ e e 3+ 3+
(desmoplastic)
Carcinoma e e 3+ 3+ 3+ 3+ e e e e
(desmoplastic)
Carcinoma e e 3+ 3+ 2+ 3+ 1+ 2+ 3+ 3+
(desmoplastic)
Dysplasia (both CD and e e 3+ (both) 3+ 3+ (CD); - (RCU) 3+ e e 2+ (CD), 3+ (RCU) 3+
RCU)
Dysplasia of RCU e e 3+ 3+ e e 1+ 2+ 3+ 3+
Dysplasia (both CD and e e 3+ (both) 3+ 2+ (CD); - (RCU) 3+ 2+ (CT); 2+ 3+ (both 3+
RCU) e (RCU)
Dysplasia (both CD and e e 3+ (both) 3+ 2+ (CD); - (RCU) 3+ e e 3+ (RCU); - (CD) 3+
RCU)
Dysplasia of CD ND ND ND ND 3+ 3+ e e ND ND
Hyperplasia of CD e e 3+ 3+ 3+ 3+ e e e e
Hyperplasia (both CD 1+ (CD only) 1+ 3+ (both) 3+ 2+ (CD); - (RCU) 3+ e e 3+ (RCU); -(CD) 3+
and RCU)
Hyperplasia of CD 1+ 2+ 3+ 3+ 2+ 3+ e e e e

Reactivity (R): percentage of cells labelling (<5%, negative (); 6e25%, 1+; 26e50%, 2+; >50%, 3+).
Intensity (I): designated subjectively as mild (1+), moderate (2+) or marked (3+). Modified from Ramos-Vara et al (2017).
CD, collecting duct; RCU, renal crest urothelium; ND, not done.

Dysplasia. CDD, either alone or in combination with
carcinomatous change, was immunonegative for Aq2,
immunopositive (>50% of cells) for CK (Fig. 4D),
positive (either 26e50% or >50% of cells) for Vim
and variably positive (either 26e50% or >50% of
cells for 3/4 cases labelled) for p63. While PAX8 could
not be validated for three cases of CDD, it was positive
(either 5e25% or 26e50%) in two cases. RCUD,
either alone or in combination with carcinomatous
change, was immunonegative for Aq2 and Vim and
positive (>50% of cells) for CK and p63.
Carcinoma. All four renal carcinomas were immuno-
negative for Aq2 but immunopositive (>50% of cells)
for CK (Fig. 5A and B). All three desmoplastic carci-
nomas were positive (either 26e50% or >50% of
cells) for Vim (Fig. 5C). One desmoplastic carcinoma
was positive (5e25% of cells) for PAX8, but validity
was uncertain in the other three cases because of non-
labelling of surrounding unaffected CDs. Three carci-
nomas were positive (either 26e50% or >50% of
cells) for p63 (Fig. 5D), but one desmoplastic carci-
noma was negative.
Discussion
This study shows that proliferative lesions primarily
involving the CDs and urothelium covering the RC
are present in most cats with CKD, and that the spec-
trum of proliferative lesions ranges from simple hyper-
plasia to dysplasia and carcinoma. Moreover, this
study supports the possibility that progression of hy-
perplastic lesions to dysplasia and neoplasia in cats
could contribute to progressive loss of renal function.
In domestic cats, the only reported proliferative le-
sions of the RC associated with CKD have been sim-
ple hyperplasia of the papillary ducts and urothelium
lining the RC (Lourenço et al, 2020) and TCCs orig-
inating in the RP and invading the RC (Hanzlicek
et al, 2012). However, a range of RC proliferative le-
sions have been reported in other species. For
example, CD epithelial hyperplasia can be secondary
to chronic progressive nephropathy in rats (Frazier
et al, 2012), related to infectious bronchitis virus in
chickens (Tsukamoto et al, 1996) and a response to Af-
rican swine fever infection in pigs (Herv
as et al, 1996).
Moreover, atypical hyperplasia (dysplasia) is com-
mon in humans with toxic nephropathies (Blohme
and Johansson, 1981). In rodents, CD epithelial cells
can display plasticity, and adaptations such as hyper-
plasia develop in response to changes in electrolyte
and acidebase status (Stanton and Kaissling, 1989;
Cheval et al, 2005; Frazier et al, 2012). The concept
of renal epithelial hyperplasia and dysplasia as pre-
neoplastic lesions is well accepted in rodents and
58 J D White et al

Fig. 4. Hyperplasia and dysplasia, kidney, cat. (A) Luminal surface of hyperplastic ducts immunopositive for aquaporin 2. IHC. (B) Cell
nuclei of hyperplastic renal crest urothelium (RCUH) immunopositive for p63. Only occasional collecting duct nuclei immuno-
positive (arrow). IHC. (C) Renal crest urothelium (RCU) immunonegative for vimentin, except for an occasional basal cell (ar-
row). Collecting ducts strongly immunopositive for vimentin. IHC. (D) Hyperplastic and dysplastic (arrows) collecting ducts and
renal crest urothelium (RCU) intensely immunopositive for cytokeratin. IHC.

humans (Kirkali and Yorukoglu, 2001; Frazier et al,
2012).
As renal cancer was present in over 4% of cats with
CKD in this study, its prevalence may be higher
among cats with CKD than in the general cat popu-
lation. In this and previous studies, renal carcinomas,
including bilateral TCCs, were present in cats with
long-standing CKD (Raffan et al, 2008; Hanzlicek
et al, 2012). Laboratory rats, mice and humans with
CKD are at increased risk of developing renal cancers
(Frazier et al, 2012; Russo, 2012; Hard et al, 2013).
Toxic nephropathies, specifically aristolochic acid
and phenacetin nephropathies, are associated with
both tubulointerstitial nephritis, urothelial atypia
and renal carcinoma in humans (McCredie et al,
1986; Yang et al, 2014; Jelakovi
c et al, 2019). Humans
with end-stage renal failure receiving haemodialysis
or transplantation are at risk of developing renal
cystic disease and carcinomas regardless of the cause
of the renal disease (Stewart et al, 2003; Stengel,
2010; Russo, 2012).
Uraemic toxins, viral mediators, immune inhibition
and upregulation of adult stem cells are proposed to
play a role in the initiation or progression of various
renal cancers in humans (Russo, 2012; Woldu et al,
2014). Studies of human CD tumours reveal hyper-
plastic and dysplastic ducts adjacent to carcinoma cells,
supporting a progression from simple hyperplasia and
regeneration (Nørgaard and Skaarup, 1985; Kirkali
and Yorukoglu, 2001; Kuroda et al, 2002). Genetic ev-
idence suggests concordant genetic regulation of renal
regeneration and carcinoma, as 77% of genes expressed
in the processes of renal repair and regeneration are
also expressed in renal cell carcinoma (Riss et al,
2006). In the case of renal papillary tumours, this
may involve the medullary progenitor stem cells, whose
normal role in the renal papilla is CD repair and regen-
eration (Oliver et al, 2004; Chen et al, 2014).
 Renal Crest Lesions in Cats with Chronic Kidney Disease 59

Fig. 5. Renal carcinoma, kidney, cat. (A) Strong immunolabelling of cytokeratin (arrows). IHC. (B) Neoplastic cells strongly immuno-
positive for cytokeratin (arrows) with apparent origin in an area of dysplastic renal crest urothelium. Hyperplastic renal crest ur-
othelium (RCUH) present at margins. IHC. (C) Neoplastic cells (arrows) and surrounding stroma (S) immunopositive for
vimentin. IHC. (D) (Same carcinoma as in Fig. 5B). Nuclear immunopositivity for p63 (arrows). Lumen (L) of renal pelvis adja-
cent to renal crest urothelium. IHC.

In our study, cats with RC carcinoma and one case
with CDD had concurrent papillary necrosis or exten-
sive medullary fibrosis, suggesting a likely association.
In humans, there is an association between medullary
and pelvic carcinoma and papillary necrosis, but it is
unclear whether one leads to the other or whether
they both develop due to similar predisposing factors
(Bach and Hardy, 1985; Brix, 2002). Drug toxicity
studies in dogs, monkeys and rats have identified
CD and urothelial necrosis, with responsive hyperpla-
sia, occurring in association with papillary necrosis
with some medications (Jacobsen et al, 1982; Mazue
et al, 1993; Kashida et al, 1996; Uehara et al, 2005).
However, progression of hyperplasia to neoplasia
has not been shown.
In this investigation, as in a previous study of cats
(Henry et al, 1999), it was difficult to identify the
cell of origin for RC cancers. A consensus approach
was required for final classification of the five cases
of dysplasia and the four cases of carcinoma. In
particular, there was vigorous debate over whether
the cell of origin was the CD epithelium or the
RCU for the four carcinomas, and this was the
main impetus for implementing IHC studies, based
on similar issues in humans (Shen et al, 2012). It could
be argued, however, that this distinction may not be
practical or necessary, as both tissues share a common
embryological origin (mesonephron) and the
neoplastic processes show similar biological behav-
iour, at least in humans (Orsola et al, 2005).
The relatively loose terminology used to describe
neoplasms of the renal papillae in animals contrasts
with the strictly defined neoplasms described in hu-
mans, which distinguishes between renal medullary
carcinoma, CD carcinoma (CDC; originally carcinoma
of the collecting ducts of Bellini) and TCC of the RP
(Srigley et al, 2013). CDC and TCC share some com-
mon features as they both develop from a site where
CDs join with urothelium lining the renal papillae.
CDC in humans is generally positive for certain CKs
60 J D White et al
(eg, CK19, high molecular weight CK) and Vim, while
pelvic urothelial tumours are CK positive but Vim
negative (Rumpelt et al, 1991). Similarly, renal medul-
lary carcinoma can be positive for a variety of CKs and
Vim (Liu et al, 2013). Both p63 and PAX8 have been
used as immunomarkers to differentiate CDC from
RP TCC in humans as CDCs are commonly PAX8 pos-
itive but p63 negative, while RP TCCs show the oppo-
site labelling characteristics (Albadine et al, 2010).
Their differentiation using IHC, however, is not abso-
lute (Urist et al, 2002; Albadine et al, 2010; Carvalho
et al, 2012; Chang et al, 2013).
In our study, it was difficult to reach a conclusion
concerning the cell of origin for the four carcinomas
as all were CK positive and three were Vim positive.
PAX8 and p63 immunolabelling was not definitive,
with one carcinoma positive for both immuno-
markers, while another was negative for both. More-
over, negativity in all four tumours for Aq2,
commonly detected in normal and hyperplastic CDs
in our study, does not preclude that cell of origin, as
its loss of expression has been reported in human renal
tumours (Mazal et al, 2005). Consequently, it might
be prudent to designate them as RC carcinomas
potentially arising from a medullary progenitor
stem cell (Oliver et al, 2004; Chen et al, 2014).
The identification of the cell of origin for medullary
and renal papillary tumours in animals has focussed
on histomorphology more than IHC, although there
are limited reports of using IHC to characterize renal
carcinomas in cats. Renal cell carcinomas were gener-
ally labelled for CD10, CD20 and CKs, especially
CK7 and CK20 (Espinosa de los Monteros et al,
1999; Bonsembiante et al, 2016; Ramos-Vara et al,
2017; Matsumoto et al, 2018). One cat with an ocular
metastasis of a RP TCC was CK7 positive but CD20
negative (Grader et al, 2016). In contrast, a single sar-
comatoid RCC was Vim positive but had variable
CK staining (Gulbahar et al, 2013). However, few of
these reports identify the site of origin or whether
medullary involvement occurred.
The implications of RC lesions for progression of
CKD and clinical disease are not fully understood,
but damage to the principal and intercalated cells of
the CD could have significant effects on water, elec-
trolyte and acidebase balance (Kokko, 1987;
Sampogna and Al-Awqati, 2013; Roy et al, 2015).
The presence of localized RC haemorrhage and fibrin
deposits, associated with dysplasia and neoplasia,
may have implications for the formation of dried solid
blood calculi within the pelvis and proximal ureter
(Westropp et al, 2006). Whether epithelial hyperpla-
sia is an adaptive response to the increased workload
or electrolyte derangements of CKD, or is a response
to toxic or infective insults, remains unknown but hae-
morrhage or dysplastic or neoplastic transformation
could contribute to progressive renal disease.
In conclusion, the cause of RC epithelial hyperpla-
sia and dysplasia in cats with CKD is unknown but
given that such changes are present in most cats
with CKD at necropsy, their potential contribution
to the progression of CKD and the development of
carcinomas warrants further investigation.
Acknowledgments
Richard Malik’s position is supported by the Valen-
tine Charlton Bequest. Drs Randolph Baral and Me-
lissa Catt provided many of the renal specimens.
Elaine Chew and Karen Barnes provided excellent
technical assistance in histology. Drs Anne Crowley
and Chris Lauer offered second opinions on histolog-
ical interpretation.
Funding
This study was partly funded by the Australian Com-
panion Animal Health Foundation.
CRediT Author Statement
Joanna D White: Data curation, Writing - Original
draft preparation, Resources. Katrina L Bosward:
Investigation, Methodology. Jacqueline M Norris:
Conceptualization, Methodology, Reviewing and
Editing. Richard Malik: Reviewing and Editing.
Scott A Lindsay: Investigation, Methodology.
Paul J Canfield: Investigation, Reviewing and Edit-
ing.
Conflict of Interest Statement
The authors declared no potential conflicts of interest
with respect to the research, authorship or publica-
tion of this article, Methodology.
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½ Received, February 13th, 2021
Accepted, July 8th, 2021