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U0 7-394. #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: 1 st kidney transplant – early rejection

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u0 7 394
U07-394

#171408800

  • Cad Tx 15 years ago
  • Recent  creatinine with mild proteinuria
  • No RAS
slide2
DOB 28-2-74
  • Hydronephrosis and hydroureter identified in neonatal period 2° to posterior urethral valves. Right nephrectomy. Ileal conduit created.
slide3
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
slide4
2006:
    • slow progressive rise in creatinine to 250 with mild proteinuria and hypertension
    • MRA did not show RAS
    • Kidney biopsy done
slide5
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.
slide15
IF
  • C4d: Strong linear peritubular capillary staining
slide17
EM
  • Will be ready next week
diagnosis renal biopsy
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
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.