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.