1. U05-23444 # 810986310 Kidney-pancreas transplant several years ago. Recent increase in creatinine with some proteinuria. Pancreas working well.

2. Case summary This 45 year man had chronic renal failure pressured to be on the basis of type I diabetes mellitus and after several years of peritoneal dialysis, he received a kidney/pancreas transplant on 31/12/1998 His post-transplant course was complicated by a number of intra-abdominal problems requiring several laparotomies, bowel resection and ileostomy which was closed on 21/01/2000.

3. After all this he ended up with serum creatinine in the 160 – 180  mol/L range with normal glycemia. Serum creatinine climbed above 200  mol/L in the Summer of 2005 and this climb continued to ~ 260  mol/L, resulting in a biopsy being performed on 7/12/2005. The biopsy was reported on 6/2/2006 leading to a request for review. Serum glucose levels remain normal. Trace proteinuria has been reported since 2001 with protein:creatinine ratio being variable in the 30 – 80 range.

4. IF IgG- Moderate linear GBM staining. IgA- Negative. IgM- Trivial to mild mesangial staining. C3- Moderate vascular staining. C1q- Negative. Kappa- Negative. Lambda- Negative. Fibrin- Mild interstitial staining. Albumin- Moderate linear GBM staining.

5. IgG

6. IgM

7. C3

8. Fibrin

9. Albumin

12. Diagnosis Renal Biopsy (7 yrs post-transplantation): -Diffuse glomerulosclerosis with features suggesting recurrent or de novo diabetic nephropathy. -Moderate parenchymal atrophy and scarring. -Slight numbers of paramesangial deposits suggesting superimposed mild IC GN. Banff scores: g0 cg1 i1 ci2 t0 ct2 v0 cv2 ah2 mm2