66 F PMH: HTN, Gout, DVT (Feb/06 and ? Sep/06) PMH: Heterozygous for Prothrombin mutation. FOCAL PROLIFERATIVE IMMUNE COMPLEX GN (toward chronic GN) 

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Presentation transcript:

66 F PMH: HTN, Gout, DVT (Feb/06 and ? Sep/06) PMH: Heterozygous for Prothrombin mutation. FOCAL PROLIFERATIVE IMMUNE COMPLEX GN (toward chronic GN)  Biopsy done in 2004, pANCA positive. On PD then switch to HD on May 2006 Medications on admission: Fragmin, Replavite, Crestor Living Related Kidney Transplant (14-Nov- 06)

U # Native kidney 64 y.o. female with Cr 188, 3+ hemoglobinuria, about 300  g proteinuria Vasculitic work-up negative

IF IgG- Minimal wipsy mesangial staining, looks just discernibly above background. IgA- Negative. IgM- Minimal to mild fine granular mesangial staining. C3- Mild vascular and vascular pole staining. C1q- Negative. Kappa- Trace level fine granular mesangial staining. Lambda- Negative. Fibrinogen- Mild to moderate interstitial staining. Albumin- Moderate background with mild hyaline droplet change in tubular cytoplasm.

IgG

IgM

C3

Kappa

Fibrin

Albumin

Diagnosis Renal Biopsy: Focal proliferative immune complex glomerulonephritis progressing toward chronic glomerulonephritis.

Ms. CH 66 F PMH: HTN, Gout, DVT (Feb/06 and ? Sep/06) PMH: Heterozygous for Prothrombin mutation. FOCAL PROLIFERATIVE IMMUNE COMPLEX GN (toward chronic GN)  Biopsy done in 2004, pANCA positive. On PD then switch to HD on May 2006 Medications on admission: Fragmin, Replavite, Crestor Living Related Kidney Transplant (14-Nov- 06)

U # LRD Tx

Diagnosis Renal Biopsy (at time of implantation): No specific diagnostic findings Minimal arteriosclerotic vascular changes

Hospital Course: Excellent/ immediate post-op kidney function. Hypotension and low Hgb: 3 units PRBC Immunosuppression: 1.Belatacept (Belatacept benefit study) 2.Prednisone 3.MMF Meds on discharge: Crestor, Valganciclovir, Replavite, Losec, MMF, Prednisone, Benefit008 study drug, phosphate, senokot, Fragmin. Started on coumadin Nov 28 th.

Creatinine started to rise Nov 28 th. Developed macroscopic hematuria Dec 2 nd.

Follow up Visits: Other work up: -LD, T. Bili, ALT: NL -P-ANCA + -PBS: NL -Hapto: Pending -Peak creatinine 204 µmol/L Dec 8 th -Hem/Onc Consult on Dec 13 th Date:Creat: Nov Nov Nov 3097 Dec 1120 Dec 6162 (1 st Bx) Dec (2 nd Bx) Dec 14189

Kidney Biopsies ?

U # LRD Tx 14/11/06 Creat 70  140 over several days

IF C4d- Negative.

EM Will follow in the coming weeks

Diagnosis Renal Biopsy (1 week post-Tx): Tubular hemorrhage and injury Further report to follow Banff score: G0 I1 T1 V0 AH0 Biopsy of marginal adequacy

U # LRD kid Tx 1 month ago Creat 70  200 Previous biopsy 1 week ago Why blood in tubules ? With proteinuria

IF C4d- Negative.

EM Will follow in the coming weeks

Diagnosis Renal Biopsy (1 month post-transplantation) Thrombotic microangiopathy of uncertain etiology –Banff score: G0 I1 T1 V0 AH0 –Further report to follow Tubular hemorrhage, injury, and regenerative features