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U0 7-394

U0 7-394. #171408800 Cad Tx 15 years ago Recent  creatinine with mild proteinuria No RAS. DOB 28-2-74 Hydronephrosis and hydroureter identified in neonatal period 2 ° to posterior urethral valves. Right nephrectomy. Ileal conduit created. 1979: 1 st kidney transplant – early rejection

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U0 7-394

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  1. U07-394 #171408800 • Cad Tx 15 years ago • Recent  creatinine with mild proteinuria • No RAS

  2. DOB 28-2-74 • Hydronephrosis and hydroureter identified in neonatal period 2° to posterior urethral valves. Right nephrectomy. Ileal conduit created.

  3. 1979: 1st kidney transplant – early rejection • 1983: back on dialysis • 1984: 2nd transplant – early rejection with subsequent renal failure – not returned to dialysis! • 1986: 3rd transplant March • 1995: Biopsy IgA, creat 500 – PD started • 1997: October • 4th transplant • On prednisone, cellcept, tacrolimus • Base creatinine 130 • Persistant enterococus UTI • Creatinine unstable over several years • 2002 serum creatinine settled down about 160

  4. 2006: • slow progressive rise in creatinine to 250 with mild proteinuria and hypertension • MRA did not show RAS • Kidney biopsy done

  5. IF • IgG- Moderate linear GBM staining. • IgA- Moderate mesangial staining. • IgM- Mild mesangial staining with some granular extension to peripheral capillary loops. • C3- Moderate vascular staining. Mild mesangial staining. • C1q-Negative. • Kappa-Negative. • Lambda- Mild to moderate mesangial staining. • Fibrinogen- Mild to moderate interstitial staining. Mild to moderate mesangial staining. • Albumin- Moderate hyaline droplet change in tubular cytoplasm.

  6. IgG

  7. IgA

  8. IgM

  9. C3

  10. C3

  11. Lambda

  12. Fibrin

  13. Fibrin

  14. Albumin

  15. IF • C4d: Strong linear peritubular capillary staining

  16. C4d

  17. EM • Will be ready next week

  18. DiagnosisRenal Biopsy: • Chronic active Ab-mediated rejection with chronic transplant glomerulopathy • with a background of IgA nephropathy and anti-GBM Ab disease, both being documented by IF findings • C4d is positive and Ab-mediated rejection is likely to be the most important of the 3 disease entities present • Banff scores: • G0 CG2 I2 CI1 T1 CT1 V0 CV1 AH3 MM2 PTC3

  19. Comment • 3 concurrent diseases • Impossible to say with certainty which is the predominant disease process • Ab-mediated damage appears quite important: • aggregates of cells in PTC • chronic tg • C4d+ and may likely be the predominant process.

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