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We have had a case of sudden graft loss after over 2 years post-transplant, with an unusual histology.  I would be interested in your thoughts.

The clinical history is a 44 year old male, ESRD due to reflux nephropathy, first cadaveric renal transplant 1999 with good function.  He recently had moderately severe hypertension, and ACE inhibitor therapy was started.  On 3rd January 2002, he was seen at a clinic obviously unwell, with sudden loss of function, anuric, sCr had increased from 170 to 440umol/l and febrile.  Perfusion scan showed renal artery occlusion.  No biopsy was performed; he had a transplant nephrectomy the next day.

The kidney, on slicing, showed diffuse cortical pallor and multifocal paler cortical areas.  The main renal artery appeared thrombosed.

 

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On microscopy, multifocal areas of cortical infarction with an interstitial neutrophil polymorph infiltrate at edge of infarcts.

 

Non-infarcted cortex showed congestion, ATN and patchy mild chronic tubulointerstitial damage. There is very mild focal interstitial inflammation away from infarcts, and there is no tubulitis.

 

There are thrombosed arteries at the hilum and in the parenchyma with associated widespread predominantly intimal acute arteritis of small, medium and large vessels.  The arteritis is transmural in some vessels, not all show associated thrombosis, and is characterised by a predominantly neutrophil polymorph infiltrate.  No fibrinoid necrosis of arteries is identified.  Arteries also show mild chronic intimal fibrosis, and some show a more cellular intimal fibrosis and appearances suggesting recanalisation of organised thrombus.

In summary, there is multifocal cortical infarction, arterial thromboses, a polymorph-rich non-necrotising arteritis, ATN and mild chronic allograft nephropathy.

Banff scores: g0,i1,t0,v3,ah0,cg0,mm0,ci1,ct1,cv1

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