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Acute Rejection Classification

Acute Rejection Classification. Cell-mediated rejection: Types 1,2,3 (tubulointerstitial, vascular, transmural) as before

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Acute Rejection Classification

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  1. Acute Rejection Classification • Cell-mediated rejection: Types 1,2,3 (tubulointerstitial, vascular, transmural) as before • Antibody-mediated rejection (“suspicious” if C4d or antibody negative) 1 ATN-like changes with C4d and circ. anti HLA antibody 2 Capillary- glomerulitis, polys and monos in PTC with circ. anti HLA antibody &/or C4d. 3 Arterial - transmural inflammation/fibrinoid change with circ. anti HLA antibody &/or C4d.

  2. V3 in Cell Mediated Rejection Kim Solez, M.D. and Alexei Sukhanov, M.D

  3. V3 in Cell Mediated Rejection • V3 common in transplant nephrectomies: • Following withdrawal of immunosuppression. • Often C4d not done. • Some cases almost certainly represent severe cell mediated rejection. • Is V3 found in severe cell mediated rejection on biopsy?

  4. Two Cases of V3 on biopsy in Cases of Cell mediated rejection since 1997 • Both had features of cell mediated rejection: • C4d Negative • Tubulitis. • Clinical history not suggestive of antibody.

  5. Two Biopsy Cases - Negative for C4d • M.T. Tx - 18 March 1997 • Bx # 1. 18 March 1997 (baseline Bx) - No diagnostic changes (G0 I0 T0 V0 AH1) • Bx #2. 25 March 1997 . History -? Rejection Dx: possible CsA tox with endothelial injury superimposed on acute interstitial rejection. • Bx #3. 03 April 1997 . History: Recent creat rise, Acute rejection? Dx: Severe "vascular" rejection with minimal tubulointerstitial component. (G0 I2 T1 V3 AH0)

  6. Two Biopsy Cases - Negative for C4d • JV Tx -18 August 1999 • Bx # 1. 18 August 1999(baseline) - Mild degenerative tubular changes withhyaline arteriolar thickening. (G0 I0 T0 V0 AH1) • Bx#2 2. 12 November 1999 . Base creat. 140, but now unstable + over 200. Dx: Acute vascular rejection with probable viral infection(?BK-virus), (G0 I3 T3 V1 AH0) • 3. 03 December 1999 Rebiopsy as creat starting to change. Dx:Severe acute rejection (category 3) Banff score G0 I2 T2 V3 CG0 Ci1 CT1 CV1 AH0

  7. Two Biopsy Cases - Negative for C4d • JV Tx -18 August 1999 • Bx # 1. 18 August 1999(baseline) - Mild degenerative tubular changes withhyaline arteriolar thickening. (G0 I0 T0 V0 AH1) • Bx#2 2. 12 November 1999 . Base creat. 140, but now unstable + over 200. Dx: Acute vascular rejection with probable viral infection(?BK-virus), (G0 I3 T3 V1 AH0) • 3. 03 December 1999 Rebiopsy as creat starting to change. Dx:Severe acute rejection (category 3) Banff score G0 I2 T2 V3 CG0 Ci1 CT1 CV1 AH0

  8. Conclusions • V3 does occur in cell mediated rejection • Classification has to accept occurrence of V3 in both cell mediated and antibody mediated rejection.

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