A nanopathology pipeline for clinical research across scales using human tissue

Most human tissue collected in clinic for diagnosis of pathology is formalin fixed and paraffin embedded or snap frozen, both of which destroy ultrastructure, making them unsuitable for clinical research requiring high resolution imaging. For diagnosis of some pathologies, most commonly renal and ciliopathies, a portion of the tissue is preserved optimally for ultrastructural imaging using electron microscopy (EM), but molecular antigenicity is masked. To resolve this incompatibility, we propose a protocol for fixation of human tissue in the clinic in EM-grade formaldehyde in phosphate buffer, which stabilises tissue for at least a year and preserves both ultrastructure and molecular antigenicity. To leverage this tissue for clinical research, we developed a new nanopathology pipeline and applied it to study intravascular immune cells in kidney biopsies from patients with a transplant. In contrast to routine diagnostic practice, which images only a few percent of the whole biopsy in 2D, the nanopathology pipeline images the microstructure of the entire biopsy with X-rays using high throughput tomography (HiTT), assigns identity to immune cells using non-permeabilisation immunolabelling and confocal fluorescence microscopy of 60 {micro}m-thick slices in regions of interest (ROIs; glomeruli and peritubular capillaries), and then images those ROIs using volume EM, specifically serial block face scanning EM. Multimodal registration of all imaging datasets into the same virtual 3D space enables extraction of nanoscale features from patient tissue that had previously only been observed in in vitro or animal models. The established nanopathology pipeline could be optimised for application to clinical research investigating a range of pathologies in the future, and with sufficient speed-up could also find application in next generation diagnostic pathways.