U07-174

#230080120

• Original disease DIC.

• Cad Tx 5 years ago.

• Creat about 90.

• Not diabetic.

U07-00174

• 24 year old Asian female

• meningococcemia at age 17 with purpura fulminans, digital infarcts/amputations, and irreversible ARF

• deceased donor renal Tx 16 November 2001; 2 yr old pediatric donor

• 7% flow PRA against class II HLA, negative against class I HLA

• good initial function

• maintenance immunosuppression with prednisone, MMF and cyclosporine (2h levels 500-800 µg/L); reduced MMF 500 mg BID due to leukopenia

• baseline creatinine 80-95 µM

• creep in creatinine to 95-105 µM through 2006; 114 µM in January 2007

• normal urinalysis with protein/creatinine ratio 11 mg/mmol in Oct 2005; trace protein in January 2007 (protein/creatinine ratio pending)

• retrospective flow B cell XM positive against donor at time of Tx; currently stronger. T cell XM also positive ?real. Flow PRA 20-35% against class II.

• Bx performed which reveals…..

IF• IgG- Mild cytoplasmic staining of interstitial plasma cells. • IgA- Negative.• IgM- Trivial to mild mesangial staining. • C3- Moderate vascular staining. • C1q- Mild to moderate patchy granular staining along the

periphery of capillary loops. • Kappa and Lambda- Moderate numbers of interstitial

plasma cells with cytoplasmic staining. • Fibrinogen- Mild interstitial staining. • Albumin- Mild hyaline droplet change in tubular

cytoplasm.

IgG

IgM

C3

C1q

kappa

lambda

fibrin

albumin

IF

• C4d: Moderate linear peritubular capillary staining.

C4d

C4d

EM

• is pending

DiagnosisRenal Biopsy (5 years post-Tx):• Ab-mediated rejection with:

– diffuse C4d positivity– peritubular capillaritis– glomerular double contours consistent with

chronic transplant glomerulopathy

• Moderate parenchymal atrophy and scarring• Banff scores:

– G1 CG2 I1 CI2 T0 CT2 V0 CV0 AH1 MM1