Consult Report - Case 33 [P97-230]

Contributed by Parmjeet S. Randhawa, M.D.

PATIENT HISTORY: The patient is an elderly male. No clinical history is received with the specimen.

Final Diagnosis (Case 2)

ALLOGRAFT KIDNEY, NEEDLE BIOPSY -

ACUTE REJECTION, MILD TO MODERATE, BANFF GRADE I/II (g0, i2, t2/3, v0).

COMMENT:
The histologic diagnosis of rejection is based on the presence of active interstitial mononuclear infiltration associated with t2/t3 tubulitis. The rejection reaction is somewhat unusual, in that it is based predominantly in the medulla.

Discussion with Dr. Ron Shapiro indicates that this is a protocol biopsy in a patient, who is clinically stable. This is presumably because the extent of parenchymal injury is insufficient to have caused a demonstrable rise in serum creatinine. Maintenance of the current immunosuppression, and close clinical monitoring is suggested. Whether active treatment of subclinical rejection episodes influences long-term graft survival has not yet been definitively established.

Previous Biopsies on this Patient:
NONE

Gross Description - Case 2

The specimen consists of one (1) consult slide. No report is received with the specimen.

Microscopic Description - Case 2

BANFF SCORING OF RENAL ALLOGRAFT BIOPSIES

1. Glomerulosclerosis

1.1 Number of glomeruli (14)

1.2 Number globally sclerotic (1)

1.3 Segmental sclerosis ( )YES (X)NO

2. Glomerulitis (X)0 ( )1 ( )2 ( )3

3. Interstitial inflammation ( )0 (X)1 ( )2 ( )3

4. Intimal arteritis (X)0 ( )1 ( )2 ( )3

5. Tubulitis ( )0 ( )1 (X)2 ( )3

6. Arteriolar hyalin ( )0 (X)1 ( )2 ( )3

7. Chronic glomerular change (X)0 ( )1 ( )2 ( )3

8. Interstitial fibrosis (X)0 (X)1 ( )2 ( )3

9. Tubular atrophy (X)0 (X)1 ( )2 ( )3

10. Vascular intimal sclerosis ( )0 (X)1 ( )2 ( )3

11. Other Findings Infiltrate predominantly in medulla, with small foci present in the cortex as well; venulitis involving medium-sized vessels.

12. Diagnostic categories

12.1 Acute rejection (KDAR_) [g,i,t,v codes]:

( ) Grade 0 (Normal)(i0, t0, v0)
( ) Grade B (Borderline)(i0-1, t0-1, v0)
(X) Grade 1 (Mild)(i1-3, t2, v0)
(X) Grade 2 (Moderate)(i1-3, t1-3, v1-2)
( ) Grade 3 (Severe)(i1-3, t1-3, v3)

12.2 Chronic allograft nephropathy (KDCR_) [cg,ci,ct,cv codes]:

( ) Grade 1 (Mild)(ci1-3, ct2, cv0)
( ) Grade 2 (Moderate)(ci1-3, ct1-3, cv1-2)
( ) Grade 3 (Severe)(ci1-3, ct1-3, cv3)

12.3 Drug-associated changes (KDDR): ( )

12.4 Acute tubular necrosis (KDAT): ( )

12.5 Donor diseases (KDDO): ( )

12.3 Other:

( ) Recurrent disease
( ) Subcapsular injury
( ) CMV
( ) Obstruction
( ) Vascular thrombosis

( ) Pyelonephritis
( ) PTLD
( ) Reflux
( ) Miscellaneous

1. Glomerulosclerosis
1.1 Number of glomeruli	(14)
1.2 Number globally sclerotic	(1)
1.3 Segmental sclerosis	( )YES	(X)NO
2. Glomerulitis	(X)0	( )1	( )2	( )3
3. Interstitial inflammation	( )0	(X)1	( )2	( )3
4. Intimal arteritis	(X)0	( )1	( )2	( )3
5. Tubulitis	( )0	( )1	(X)2	( )3
6. Arteriolar hyalin	( )0	(X)1	( )2	( )3
7. Chronic glomerular change	(X)0	( )1	( )2	( )3
8. Interstitial fibrosis	(X)0	(X)1	( )2	( )3
9. Tubular atrophy	(X)0	(X)1	( )2	( )3
10. Vascular intimal sclerosis	( )0	(X)1	( )2	( )3
11. Other Findings	Infiltrate predominantly in medulla, with small foci present in the cortex as well; venulitis involving medium-sized vessels.
12. Diagnostic categories
12.1 Acute rejection (KDAR_) [g,i,t,v codes]:	( ) Grade 0 (Normal)(i0, t0, v0) ( ) Grade B (Borderline)(i0-1, t0-1, v0) (X) Grade 1 (Mild)(i1-3, t2, v0) (X) Grade 2 (Moderate)(i1-3, t1-3, v1-2) ( ) Grade 3 (Severe)(i1-3, t1-3, v3)
12.2 Chronic allograft nephropathy (KDCR_) [cg,ci,ct,cv codes]:	( ) Grade 1 (Mild)(ci1-3, ct2, cv0) ( ) Grade 2 (Moderate)(ci1-3, ct1-3, cv1-2) ( ) Grade 3 (Severe)(ci1-3, ct1-3, cv3)
12.3 Drug-associated changes (KDDR):	( )
12.4 Acute tubular necrosis (KDAT):	( )
12.5 Donor diseases (KDDO):	( )
12.3 Other:	( ) Recurrent disease ( ) Subcapsular injury ( ) CMV ( ) Obstruction ( ) Vascular thrombosis	( ) Pyelonephritis ( ) PTLD ( ) Reflux ( ) Miscellaneous

Please mail comments, corrections or suggestions to the TPIS administration at the UPMC.