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1979: 1 st kidney transplant – early rejection 1983: back on dialysis 1984: 2 nd transplant – early rejection with subsequent renal failure – not returned to dialysis! 1986: 3 rd transplant March 1995: Biopsy IgA, creat 500 – PD started 1997: October –4 th transplant –On prednisone, cellcept, tacrolimus –Base creatinine 130 –Persistant enterococus UTI –Creatinine unstable over several years 2002 serum creatinine settled down about 160
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U07-394
#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: 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
• 2006: – slow progressive rise in creatinine to 250 with
mild proteinuria and hypertension– MRA did not show RAS– Kidney biopsy done
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.
IgG
IgA
IgM
C3
C3
Lambda
Fibrin
Fibrin
Albumin
IF
• C4d: Strong linear peritubular capillary staining
C4d
EM
• Will be ready next week
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
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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