U0 7 - 174

1. U07-174 #230080120 • Original disease DIC. • Cad Tx 5 years ago. • Creat about 90. • Not diabetic.

2. U07-00174 • 24 year old Asian female • meningococcemia at age 17 with purpura fulminans, digital infarcts/amputations, and irreversible ARF • deceased donor renal Tx 16 November 2001; 2 yr old pediatric donor • 7% flow PRA against class II HLA, negative against class I HLA • good initial function • maintenance immunosuppression with prednisone, MMF and cyclosporine (2h levels 500-800 µg/L); reduced MMF 500 mg BID due to leukopenia • baseline creatinine 80-95 µM • creep in creatinine to 95-105 µM through 2006; 114 µM in January 2007 • normal urinalysis with protein/creatinine ratio 11 mg/mmol in Oct 2005; trace protein in January 2007 (protein/creatinine ratio pending) • retrospective flow B cell XM positive against donor at time of Tx; currently stronger. T cell XM also positive ?real. Flow PRA 20-35% against class II. • Bx performed which reveals…..

3. IF • IgG- Mild cytoplasmic staining of interstitial plasma cells. • IgA-Negative. • IgM- Trivial to mild mesangial staining. • C3- Moderate vascular staining. • C1q- Mild to moderate patchy granular staining along the periphery of capillary loops. • Kappa and Lambda- Moderate numbers of interstitial plasma cells with cytoplasmic staining. • Fibrinogen- Mild interstitial staining. • Albumin- Mild hyaline droplet change in tubular cytoplasm.

4. IgG

5. IgM

6. C3

7. C1q

8. kappa

9. lambda

10. fibrin

11. albumin

12. IF • C4d: Moderate linear peritubular capillary staining.

13. C4d

14. C4d

15. EM • is pending

16. DiagnosisRenal Biopsy (5 years post-Tx): • Ab-mediated rejection with: • diffuse C4d positivity • peritubular capillaritis • glomerular double contours consistent with chronic transplant glomerulopathy • Moderate parenchymal atrophy and scarring • Banff scores: • G1 CG2 I1 CI2 T0 CT2 V0 CV0 AH1 MM1