Contributed by Parmjeet Randhawa, M.D.
PATIENT HISTORY: The patient is status post cadaver pancreas and kidney transplant two months ago for diabetes. He is currently on Cyclosporin and corticosteroids. Pertinent laboratory data: Creatine has risen from baseline of 0.8 to 1.6. Rule out rejection. Patient is on tube feeding since transplantation. Could this be the cause of focal calcification near the tubules? Metabolic disorder?
PRE OP DIAGNOSIS: Rule out rejection.
POST OP DIAGNOSIS: Same.
PROCEDURE: Transplant kidney biopsy.

Final Diagnosis (Case 8)

PART 1: ALLOGRAFT KIDNEY, NEEDLE BIOPSY-
  1. TUBULAR AND MYOCYTE VACUOLIZATION (See comment).
  2. TUBULAR AND PERITUBULAR CALCIFICATIONS (See comment).

Tubular & myocyte vacuolization is a morphologic criterion for drug toxicity, provided other ischemic & metabolic insults have been reasonably excluded.

Calcification in the allograft kidney is generally of the dystrophic type, and reflects prior injury due to ischemia, drug toxicity or rejection. A small proportion of cases result from hyperparathyroidism occurring secondarily to end-stage renal disease in the native kidney. Correlation with the clinical findings and serum biochemistry is suggested.

This biopsy also contains a minimal interstitial infiltrate which does not qualify for the diagnosis of acute rejection. However, the sample contains only 7 glomeruli, and 1 artery, and falls short of the Banff criteria for specimen adequacy. If the patient' s clinical status continues to deteriorate, a repeat sample may be helpful.

Previous Biopsies on this Patient:
None

TPIS Related Resources:
Kidney Transplant Topics


Gross Description - Case 8

Three (3) ocnsult slides.


Microscopic Description - Case 1

(2 H&E, 1 PAS)
1. Glomerulosclerosis
1.1 Number of glomeruli . . . . .(7 )
1.2 Number globally sclerotic . .(0 )
1.3 Segmental sclerosis . . . . .( )YES(x )NO

2. Glomerulitis(g). . . . . . . . . .(x )0 ( )1 ( )2 ( )3

3. Interstitial inflammation(i) . . .(x )0 (x )1 ( )2 ( )3
(check if present) . . . . . . .( )Neutrophils( )Eosinophils

4. Intimal arteritis(v) . . . . . . .(x )0 ( )1 ( )2 ( )3
( )Not evaluable 5. Tubulitis(t) . . . . . . . . . . .(x )0 (x )1 ( )2 ( )3

6. Arteriolar hyalin(ah). . . . . . .(x )0 ( )1 ( )2 ( )3
( )Not evaluable Nodular form . . . . . . . . . . .( )YES( )NO

7. Chronic glomerular change(cg). . .(x )0 ( )1 ( )2 ( )3
7b. Mesangial matrix increase (mm) . .(x)0 ( )1 ( )2 ( )3

8. Interstitial fibrosis(ci). . . . .(x )0 ( )1 ( )2 ( )3

9. Tubular atrophy(ct). . . . . . . .(x )0 ( )1 ( )2 ( )3

10. Vascular intimal sclerosis(cv) . .(x )0 ( )1 ( )2 ( )3
( )Not evaluable 10b. Number of arteries with internal elastic lamina: (1 )

11. Other findings:

12. Diagnostic categories (Check as many categories as appropriate)
( )KDARO: Normal
( )KDAB: Antibody mediated rejection
( )KDARB: Borderline change (i0-2, t0-2, v0)
( ) Acute rejection (specify g, i, t, v grades):
( )KDAR1A: Banff Type 1A (i1-3, t2, v0)
( )KDAR1B: Banff Type 1B (i2-3, t3, v0)
( )KDAR2A: Banff Type IIA (i1-3, t0-3, v1)
( )KDAR2B: Type 2B (i1-3, t0-3, v2)
( )KDAR3: Type III (i1-3, t0-3, v3)
( ) Chronic allograft nephropathy (Specify cg, ci, ct, cv grades):
( )KDCR1a: Mild, without specific changes suggesting chronic rejection
( )KDCR1b: Mild, with specific changes suggesting chronic rejection
( )KDCR2a: Moderate, without specific changes suggesting chronic rejection
( )KDCR2b: Moderate, with specific changes suggesting chronic rejection
( )KDCR3a: Severe, without specific changes suggesting chronic rejection
( )KDCR3b: Severe, with specific changes suggesting chronic rejection
(x ) KDDR: Tubular and/or myocyte vacuolization c/w drug-associated changes.
(x ) KDAT: Acute tubular necrosis.
( ) KDDO: Donor disease.
Other:
( ) Recurrent disease (specify)
( ) Subcapsular injury ( )Pyelonephritis
( ) CMV ( )PTLD
( ) Obstruction ( )Reflux
p ( ) Vascular thrombosis (specify) (x ) Miscellaneous


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