Biopsy Consult - Renal Transplant

Submitted by Dr. L. Salinas

Dear colleagues:

I need your opinion on this case: 18 y/o female. Renal transplant in 1999 (ESRD sec. to reflux nephropathy). Several episodes of "rejection", with corresponding biopsies (read at another institution) interpreted as TI rejection, all with abundant plasma cells. Suspected of polyoma infection, but never demonstrated in the tissues. The patient was referred to us. Two biopsies at our institution have shown: 1) massive loss of tubules, 2) an interstitial infiltrate with abundant or exclusive plasma cells (last biopsy: RB02-169, attached), and 3) advanced small vessels disease, with tortuosity, thickening, obliteration, and prominent hyalinization (quite consistent with calcineurin inhibitors toxicity). The patient has been compliant with treatment. Our stains for CMV, SV40 and EBV have been repeatedly negative, and the cells are polyclonal. The first C4d was negative, but the current biopsy shows diffuse prominent interstitial capillary staining.  Could this case have plasma cell mediated humoral rejection ?  What else ? the clinic and I need some guidance for appropriate treatment.

Thanks,  

Luis Salinas-Madrigal Saint Louis University

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