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Interactive Case Discussion Case 6

Interactive Case Discussion Case 6. Dr Megha S Uppin Asst Prof Dept of Pathology Nizam’s Institute of Medical Sciences Hyderabad. Case History. 30/M Renal allograft recipient (DOT: 18.8.2009) Live related transplant, Donor: Mother

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Interactive Case Discussion Case 6

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  1. Interactive Case DiscussionCase 6 Dr Megha S Uppin Asst Prof Dept of Pathology Nizam’s Institute of Medical Sciences Hyderabad

  2. Case History • 30/M • Renal allograft recipient (DOT: 18.8.2009) • Live related transplant, Donor: Mother • Immediate graft function on triple immunosupression (Tac+MMF+Prednisolone)s • No history of post operative complications, CMV, UTIs or any other complication.

  3. November 2011, Serum Creatinine: 1.5mg%)

  4. Borderline Rejection • Treated with methyprednisolone • Serum Creatinine improved • Lost to follow up for six months and omitted the medicine for 15 days. • June 2012, presented with raised serum creatinine: 10mg/dl • No uremic symptoms • No oliguria, dysuria , fever • O/E: No pallor, oedema, BP: 130/80mm Hg Per abdomen: Non tender • Clinical diagnosis: Acute rejection

  5. Investigations • CUE: pH: 5, Albumin: 3+, Pus cells: 10-15, • Hb 12.6 g%, TLC: 5600, Plt 70000/cmm • Urine Culture: sterile • Anti CMV: Negative • Serum Albumin: 3.2 • Urea: 86, Na: 113, K: 3.4, Chloride: 91, • Urine for decoy cells : Negative • Color Doppler of transplant kidney: Normal

  6. CD 138

  7. Provisional Diagnosis Plasma Cell Rich Acute Cellular Rejection

  8. C4d

  9. Final Diagnosis Acute HumoralRejEction (LATE)with Plasma Cell Infiltrate

  10. Follow Up • Treated with IV pulse Methyprednisolone • Plasmapheresis • Rituximab • However S Creatinine did not improve • Patient is dialysis dependent

  11. Plasma Cells In Renal Allograft • Viral infection BK and EBV • PTLD • Drug toxicity • Acute rejection(PCAR) • 1 month to many years post transplant • 1.8–2.5% of allograft biopsies • Plasma cells >10% of interstitial infiltrate • Poor response to antirejection therapy • HARNEY C. TRANSPLANTATION 1999;68:791–797 • R. Gupta Indian J Nephrol. 2012 May;22(3):184-8 • Chronic Allograft Damage • Xu et al 40 explanted grafts • 32.5% had both CD138+ plasma cells and diffuse C4d deposits • Martin et al • Plasma cells, DSA and C4d are associated in renal transplants developing chronic rejection • plasma cells can be present in absence of acute rejection and associated with chronic allograft damage. • Intra-graft plasma cells might be a source of Abs • Martin L. Transplant Immunology (2010)

  12. Summary :Issues in this Case • C4d is found in 24–43% of type I rejection episodes • Concurrent acute T cell rejection with C4d positive AHR is an independent risk factor for graft survival • Volker N, Mihatsch MJ. Nephrol Dial Transplant (2003) 18: 2232–2239

  13. Late AHR • AMR that occurs more than 6 months after transplantation • Mostly associated with the withdrawal or reduction of immunosuppressants than positive pretransplant PRA • Associated with IFTA • Poor outcome • Plasma cells: • Indicator of a more adverse outcome • Accompanied by the appearance or subsequent development of VR • PCAR should therefore encourage the clinician to intensify the immunosuppressive schedule • Treatment • IVIG

  14. Thank You

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