1. U06-1464 #228568920 Chronic renal failure – secondary to IgA nephropathy. Deceased donor kidney transplant – August 1999. Complicated by delayed graft function requiring dialysis. Poor compliance with follow up and blood work. Not seen between June 2002 and Nov 05. Labs Sept 04 In Nov 05 creatinine was 150 µ mol/L Had d/c steroids 2 years ago.

2. Admitted to UofA 1 week after presenting to ER with foot pain ? work related Rx with NSAIDs. On admission very hypotensive requiring ICU admission. Jan 14 th Creat was >742 µ mol/L and CsA <8. Resuscitated with IV fluids. Creatinine fell over next few days. 271 µ mol/L Jan 20 th. After this it started to rise 374 µ mol/L on Jan 23 rd. renal biopsy January 23 rd, 2006. AS Jan 23 rd Donor specific class II DR52,DQ5,DQ6 and weak DR1 antibodies. Urine 1+ protein and UTPCR 140mg/mmol Feb 08, trace Hb U06-1464

3. IF IgG- mild coarsely granular capillary loop IgA- Negative IgM- negative C3- moderate vascular staining C1q- negative Kappa- mild coarsely granular capillary loop Lambda- mild coarsely granular capillary loop Fibrin- Moderate interstitial staining Albumin- Negative C4d- mild linear PTC staining

4. IgM IgG

5. Clq C3

6. Fibrin Kappa

7. Lambda

8. Fibrin

9. C4d

15. Diagnosis: Renal Biopsy (7 years post-transplantation): 1) Mixed T-cell (acute tubulointerstitial rejection, Type IB) and antibody mediated rejection (C4d is positive) 2) Equivocal vascular changes raising the possibility of a vasculitic process which is not sampled. 3) De novo or recurrent membranous glomerulopathy with superimposed possible chronic transplant glomerulopathy. 4) Signs of acute tubular injury and regeneration 5) Moderate paranchymal atrophy and scarring. 6) Marked hyaline arteriolar thickening suggesting calcineurin inhibitor toxicity (G0 CG2 I2 CI2 T3 CT2 V0 CV1 AH3 MM2)

16. 228568920 U06-3805 Cad tx Aug 99.Base creat 150.Recently admitted. Creat 700.Biopsy.Treated as rejection. Creat now 210.? Continuing rejection activity

17. IgG- moderate coarsely granular capillary loop staining IgA- mild to moderate mesangial staining IgM- mild mesangial staining C3- mild vascular staining C1q- mild vascular staining Kappa- mild coarsely granular capillary loop staining Lambda- mild coarsely granular capillary loop staining Fibrin- mild interstitial staining Albumin- mild linear GBM staining C4d- negative IF

18. IgG

19. IgA

20. IgM

21. C3

22. Clq

23. Kappa

24. Lambda

25. Fibrin

26. Albumin

31. Diagnosis: Renal Biopsy (7 years post-transplantation): Persisting antibody mediated injury with less inflammatory infiltrate than previous biopsy. Recurrent or de novo mixed membranous and proliferative glomerulonephritis with subepithelial deposits and spikes. Possible calcineurin inhibitor toxicity. (G1 CG0 I2 CI2 T0 CT2 V0 CV0 AH3 MM1)