Recurrent Disease and Chronic Rejection in Kidney Transplant Patient: Biopsy Findings

1. U99-13179 #273396820 LRD kid tx March/99 Original Dis IgA

2. U99-13179 DOB 26/5/67 1988 kidney biopsy with diagnosis Bergers IgA nephropathy 1997 September creatinine 500 1998 June creatinine 1300-urgent hemodialysis 1999 March start kidney transplant from sister Therapy: prednisone,Neoral,MMF/rad B25/ study Stable post transplant, creatinine 80-100 μmol/L Mild proteinuria and microscopic hematuria shortly after transplant 2002 increasing proteinuria to nephrotic syndrome with serum creatinine 120-180 range Avascular necrosis femoral heads :diagnosed 14/3/06 transplant biopsy: serum creatinine 250-300 protein/creatinine 25 serum albumin 42 On;prednisolone,Cellcept,Tacrolimus,Cozar,furosemide,Norvesc, acebutolol Is all clinical + biopsy change caused by recurrent disease?

3. IF • IgG- mild linear glomerular capillary(artifact?) • IgA- negative • IgM- trace mesangial-essentially negative • C3- moderate vascular and interstitial capillary • C1q-negative. • Kappa-mild linear glomerular,similar to IgG.Also moderate tubular droplet • Lambda-mild tubular droplet only • Fibrin- minimal interstitial • Albumin- strong tubular droplet and flat background

4. IgG

5. IgM

6. Kappa

7. Albumin

11. Diagnosis: Renal Biopsy: Borderline changes. No definitive evidence of rejection Rule out bacterial infection Banff score: (G1 CG0 I1 CT1 T1 CT1 V0 CV1 AH0 MM0)

12. U00-8893 #273396820 Renal transplant 18 months ago. increased creatinine prev bx 19 June rejection

13. IF • IgG: negative • IgA: negative • IgM: mild mesangial staining • C3: negative • C1q: negative • Kappa:negative • Lambda:negative • Fibrinogen: negative • Albumin:negative • C4d: Mild arteriolar staining.none in peritubular capillary

14. IgM

15. C4d

18. Diagnosis: Renal Biopsy: Probable chronic rejection with superimposed FK506 toxicity and acute tubular necrosis Banff score: (G0.CG1.I1,CT2,T1,CT2,V0,CV2,AH1,MM1)

19. Diagnosis: Renal Biopsy: Probable chronic rejection with superimposed FK506 toxicity and acute tubular necrosis. Banff score: (G0.CG1.I1,CT2,T1,CT2,V0,CV2,AH1,MM1)

20. U06-4991 #273396820 Original disease IgA LRD tx 1999. ↑creat 2000 with biopsy Proteinuria 2003 Creat now>200 but proteinuria gone?

21. IF • IgG- moderate to strong linear GBM staining • IgA- negative • IgM- trivial mesangial staining • C3- mild vascular staining • C1q-negative. • Kappa-moderate linear GBM staining • Lambda-negative • Fibrin- mild interstitial staining/mild glomerular staining • Albumin- minimal hyaline droplet change in tubular cytoplasm and mild linear GBM staining • C4d:No tissue left for C4d staining

22. IgG

23. IgM

24. C3

25. Kappa

26. Fibrin

27. Fibrin

28. Albumin

29. Albumin

33. Diagnosis: Renal Biopsy:(seven years post-transplantation) Chronic transplant glomerulopathy with 50% Glomerulosclrerosis Moderate parenchymal atrophy and scarring. Moderate hyaline arteriolar thickening suggesting calcinurine inhibitor toxicity. No evidence of acute rejection. Banff score: (G1 CG2 I1 CI2 T0 CT2 V0 CV1AH2 MM2)