Dr. Agnes Fogo (AF; @AgnesFogo) does not need an introduction. For nephrologists, nephrology fellows, and nephropathology residents around the world, her AJKD Atlas of Renal Pathology has long been a valuable resource. Dr Fogo is currently the John L. Shapiro Professor of Pathology in the Department of Pathology, Microbiology, and Immunology, and Professor of Medicine and Pediatrics, the Director of the Renal/EM Division of Pathology, and the Director of the Renal Pathology Fellowship Program at the Vanderbilt University School of Medicine. She was the architect of the original 1999 AJKD Atlas of Renal Pathology, and now has embarked on a new, updated, and more comprehensive Atlas of Renal Pathology II that launched this month.
Dr. Fogo was interviewed by Dr. Nikhil Shah (AJKDblog; @dr_nikhilshah), a nephrology fellow at the University of Alberta, Canada. His interest in nephropathology was sparked by Dr. Fogo’s original AJKD Atlas of Renal Pathology and her textbooks during nephrology training in India.
The AJKD Atlas of Renal Pathology II can be accessed on the AJKD website. In addition to the pathology installments, a team of editors and content developers are working to provide rich content to support the main Atlas installments at the AJKD Blog. These features will include interviews, quizzes, and commentaries from opinion leaders from around the world. AJKD Atlas of Renal Pathology II and AJKD Blog together will make this project a living textbook of nephropathology, freely accessible to all.
AJKDblog: What made you choose nephropathology as a career?
AF: I chose nephropathology because of the integration of complex information in a clinical setting, and the important interactions with clinicians in reaching a diagnosis. I find solving mysteries to be challenging and rewarding, and enjoy diagnosing a patient’s disease and identifying the important features that may help in understanding etiology and possible response to therapy.
AJKDblog: Why did you feel there is need to update the AJKD Atlas of Renal Pathology, and what are the most important changes you intend to bring about?
AF: Renal pathology is an evolving field, as all other areas of medicine. There were many entities where there has been an increased understanding of specific lesions and diagnosis. In addition, the new format of this Atlas emphasizes a compact educational text in addition to the figures, and thus expands on the original Atlas.
AJKDblog: There has been a proliferation of genetic testing, molecular testing, and diagnostics in the last decade. What is the role of pathology going forward vis a vis these new methods of testing for diseases?
AF: The novel approaches to testing are, in my view, complementary to the pathologic manifestations of disease. Pathology gives information on the “stage” of the lesions, indicating the activity and chronicity of the process. Patients may have increased serum creatinine due to either chronic or active or mixed lesions. Even with the same underlying genetic mutation, different “stages” may warrant different approaches to therapy. We are then able to integrate our novel molecular and genetic understandings with the tissue, such as staining for phospholipase A2 receptor in kidney biopsies in patients with membranous nephropathy.
AJKDblog: Transplant pathology has incorporated serologic testing (eg, DSA testing and ENDATs) into classifications (eg, Banff 2013 ABMR). Do you sense that will spillover into glomerulonephritis classifications leading to a revamping of the traditional pathologic descriptions of disease?
AF: Pathology has always relied on the clinical context for the best interpretation of lesions. The repertoire of lesions in the kidney is quite limited. For instance, a biopsy may show a vigorous interstitial nephritis with tubulitis. Without the clinical context, you cannot say if this is a native kidney with a hypersensitivity drug reaction, or if this is acute rejection in the transplant. If you do not know the clinical setting, you can list lesions, but you cannot offer an integrated interpretation. Thus, I think the premise of the question is not congruent with the way renal pathology currently is practiced. I do think additional tests both from tissue, from genetics, and from serum will allow us to build further understanding of patients’ diseases.
AJKDblog: What advice would you like to give new nephrology fellows about pathology?
AF: I think nephrology fellows should be familiar with the multisyllabic terminology we use to describe lesions in renal pathology. Similarly, renal pathologists must know enough clinical nephrology to be able to understand the clinical pathologic correlations that are important to the care of the patient and for communication with the nephrologist. In my view, understanding terminology is much enhanced by understanding the dynamics of the lesion. We hope that this Atlas will allow a greater familiarity not only with the words, but with the abnormalities that lead to the patient’s clinical manifestations of disease.
AJKDblog: You recently signed up on Twitter (@AgnesFogo). What role do you think social media will play in the field of nephropathology going forward?
AF: I feel that social media is rapidly evolving, and is a new and exciting world for more senior people to enter. I am learning from my adult children, trainees, and young people how we can effectively communicate. This must be balanced by having a filter on what is appropriate and useful communication so that we enhance our learning and understanding.
AJKDblog: Where do you think nephropathology will be 10 years from now?
AF: My research work has long focused on the possibility of regressing existing glomerulosclerosis, and aims to understand the mechanisms driving progression and those that could enhance healing of chronic injuries. With novel approaches such as next generation sequencing, mass spectrometry imaging with non-biased assessment of the peptides expressed in the kidney and the promise of understanding other molecules, including for instance lipids, and their impact on tissue injury, I think we will have an integrated understanding of disease at a higher level. As these techniques become miniaturized and affordable, we may be able to have an accurate molecular staging, both with regards to underlying genetic susceptibility factors and nuances of different stages of disease that hopefully will be matched with individualized stage-specific and patient-specific therapy.