USCAP EVENING RENAL PATHOLOGY SPECIALY CONFERENCE
ATLANTA
Wednesday March 7, 2001
Moderator V. D'Agati

Clinical Presentation. The patient is a 53 year old black male with end-stage renal disease, presumed to be secondary to long-standing hypertension. Nine years prior to biopsy, he had received a cadaveric renal transplant, 6 antigen mismatch. Acute tubulointerstitial rejection was documented in the first month post-transplant. He also had ureteropyeloplasy for ureteral necrosis, and had had a CMV infection for which he was treated with Cytogam. At approximately 1 and _ years post transplant, he had suffered acute deterioration of renal function presumed to be rejection, which was treated; no biopsy was performed. Within 2 years of initial transplantation, his GFR had deteriorated to 50% of his previous stable baseline, and he had extensive chronic changes on biopsy, with focal segmental glomerulosclerosis with hyalinosis, and mixed inflammation in a fibrotic surround. IgA was documented in the mesangium by immunofluorescence, but EM was not performed. This first allograft subsequently failed, and the patient returned to hemodialysis.

Five years after the initial allograft, he received the current cadaveric renal allograft, with 4 antigen mismatch, from a young male donor. PRA prior to transplant was 14, with a peak of 30. There was a thirty hour cold ishemia time; the allograft began to function at 10 days post transplant. During the post transplant period, the patient has had hypertension, and has developed glucose intolerance due to his immunosuppressive regimen, but had had no clinically appreciable episodes of acute rejection. By sixteen months post transplant, the patient had developed significant proteinuria. A renal biopsy at that time revealed focal segmental glomerulosclerosis; this finding led to speculation that the lesion might represent a recurrence of this disease, since his native kidney disease had never been well-documented. Patchy lymphoplasmacytic infiltrates were noted in areas of parenchymal scarring, without tubulitis. In situ staining for EBV was negative.

Since that time, his creatinine clearance had been declining slowly from 80 cc/min to 65 cc/minute; creatinine was documented at 1.5 mg/dl 3 months prior to presentation. He missed several clinic appointments before returning for a follow-up visit just prior to the current biopsy, at which time laboratory studies revealed a creatinine of 6.7 mg/dl, BUN 51 mg/dl, and hematocrit is 32%. His blood pressure was 156/82. Urinalysis revealed proteinuria, quantitated at 2 grams per day, with no hematuria. On questioning, he admitted that his insurance had lapsed, and he had not taken his immunosuppressive drugs, including FK506 and prednisone, for a few weeks. The renal biopsy provided for review was obtained, 3.8 years post-transplant. Material submitted: 4 kodachromes (H&E)