U # Cad Tx 15 years ago Recent  creatinine with mild proteinuria No RAS

DOB Hydronephrosis and hydroureter identified in neonatal period 2° to posterior urethral valves. Right nephrectomy. Ileal conduit created.

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

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

Lambda

Fibrin

Albumin

IF C4d: Strong linear peritubular capillary staining

C4d

EM Will be ready next week

Diagnosis Renal 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.