Final Diagnosis (Case 6)

1. CHRONIC REJECTION WITH MODERATE TO SEVERE INTERSTITIAL FIBROSIS AND OBLITERATIVE ARTERIOPATHY (cg1,ci3,ct3,cv3).
2. ACUTE REJECTION, MODERATE, WITH INTIMAL ARTERITIS, BANFF GRADE 2 (g0,i3,t3,v2).
3. REACTIVE LYMPHOID HYPERPLASIA; IN-SITU HYBRIDIZATION FOR EPSTEIN-BARR VIRUS IS NEGATIVE.

   PART 2:
   ALLOGRAFT KIDNEY, NEEDLE BIOPSY-
   

   1. CHRONIC REJECTION WITH MODERATE TO SEVERE INTERSTITIAL FIBROSIS AND OBLITERATIVE ARTERIOPATHY (cg1,ci2-3,ct3,cv3,ah2).
   2. ACUTE REJECTION, MILD TO MODERATE, BANFF GRADE 1-2 (g0,i2-3,t3,v0-1).
   3. FOCAL VASCULAR THROMBOSIS.
   4. FOCAL LYMPHOID HYPERPLASIA; IN-SITU HYBRIDIZATION FOR EPSTEIN-BARR VIRUS IS NEGATIVE.

   Comment:
   Several foci of intense lymphoid hyperplasia are noted in the allograft nephrectomy, and one such focus is also found in the needle biopsy. These are felt to be a manifestation of allogeneic immune activation, since the degree of lymphoid atypia is within the spectrum of reactive proliferation, and there is no evidence for serpiginious necrosis. Furthermore, EBER in-situ hybridization for Epstein-Barr virus is negative. The clinical suspicion of post-transplant lymphoproliferative disease cannot be substantiated.

   Previous Biopsies on this Patient:
   None

   TPIS Related Resources:
   Kidney Transplant Topics

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   Gross Description - Case 6

   The specimen consists of nineteen (19) consult slides: Part 1 (12 slides, 8 unstained), and Part 2 (7 slides, 3 unstained). No surgical pathology report is received with the specimen.

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   Microscopic Description - Case 6

   

   PART 1
   

   BANFF SCORING OF RENAL ALLOGRAFT BIOPSIES

   1. Glomerulosclerosis
   1.1 Number of glomeruli	(Multiple)
   1.2 Number globally sclerotic	( )
   1.3 Segmental sclerosis	( )YES		( )NO
   2. Glomerulitis	(X)0	( )1	( )2	( )3
   3. Interstitial inflammation	( )0	( )1	( )2	(X)3
   4. Intimal arteritis	( )0	( )1	(X)2	( )3
   5. Tubulitis	( )0	( )1	( )2	(X)3
   6. Arteriolar hyalin	( )0	( )1	(X)2	( )3
   7. Chronic glomerular change	( )0	(X)1	( )2	( )3
   8. Interstitial fibrosis	( )0	( )1	( )2	(X)3
   9. Tubular atrophy	( )0	( )1	( )2	(X)3
   10. Vascular intimal sclerosis	( )0	( )1	( )2	(X)3
   11. Other Findings	L26 positive B-cells present within the reactive lymphoid nodules.
   12. Diagnostic categories
   12.1 Acute rejection (KDAR2) [g,i,t,v codes]:	( ) Grade 0 (Normal)(i0, t0, v0) ( ) Grade B (Borderline)(i0-1, t0-1, v0) ( ) 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 (KDCR3) [cg,ci,ct,cv codes]:	( ) Grade 1 (Mild)(ci1-3, ct2, cv0) ( ) Grade 2 (Moderate)(ci1-3, ct1-3, cv1-2) (X) 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

   

   PART 2
   The needle biopsy shows findings essentially similar to the nephrectomy, but the degree of interstitial inflammation, tubulitis and intimal arteritis are less prominent. This difference presumably reflects a reduction in immunosuppression prior to nephrectomy.

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