Pathology of Renal Transplantation

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Presentation transcript:

Pathology of Renal Transplantation

Objectives: Recognize the concept of renal allograft. Describe the pathology of rejection Differentiate between acute and chronic rejection. Recognize the principal infections inherent to renal transplantation. Recognize acute and chronic drug toxicity.

Renal transplantation Note the two end-stage native kidneys in normal position, the atrophic first donor kidney (lower left), and the larger second donor kidney (lower right).

The Banff classification:diagnostic categories Normal Hyperacute Rejection Borderline changes(“very mild acute rejection”) Acute Rejection( Tcell, Antibody-mediated) Chronic Rejection Others Others= changes not considered to be related to rejection. Hyperacute rejection is an antibody mediated endothelial damage.

Subtotal renal infarction due to hyperacute (antibody-mediated) rejection.

Infartion in hyperacute rejection.

Severe acute rejection of donor kidney. Focal infarcts are present.

The Banff classification Borderline changes(Suspicious for Acute Rejection) No intimal arteritis Mild tubulitis (1-4/tubular cross section).

Suspicious.

The Banff classification Grade I A :Mononuclear interstitial inflammation(>25%). + Moderate tubulitis.(5 to 10) Grade I B :Mononuclear interstitial inflammation(>25%) +Severe tubulitis(>10)

Acute cellular rejection

Acute rejection. The interstitial infiltrate consists of T cells mainly.

The Banff classification Grade II A Mild to Moderate intimal arteritis : Grade II B Severe intimal arteritis

Mild areteritis.

The Banff classification Grade III Transmural arteritis and/or fibrinoid necrosis.

The Banff classification Chronic Allograft Nephropathy: Grade I (Mild) Grade II (Moderate) Grade III (Severe) All is based on the tubular atrophy and interstitial fibrosis.as well as on the transplant glomerulopathy(double contour). Chronic allograft damage index.Vascular :0 <25,>25,to 50,>50.mesangial matrix increase tubular atrophy,interstitial fibrosis.

Severe chronic rejection. (graft arteriopathy) Severe chronic rejection. (graft arteriopathy). Note the severe parenchymal atrophy and the thick-walled arteries.

Transplant glomerulopathy.

Chronic/ sclerosing allograft nephropathy Chronic/ sclerosing allograft nephropathy. An example of Grade II-III is characterized by a diffuse increase in interstitial tissue and marked tubular atrophy as seen on this trichrome stain.

The Banff classification Normal, Suspicious Grade I Grade II Grade III Cyclosporine toxicity Acute Tubular Necrosis Chronic rejection No Treatment Treat if clinical signs+ Treat Treat or Abandon Reduce Cyclosporine Await recovery or treat Temporize Treat grade II with steroids and consider ALG/OKT3.

Infections Recurrent or De Novo GN

Intranuclear viral inclusion. Ground glass.

DRUG TOXICITY

Acute Cyclosporine Toxicity: Isometric vacuolisation

Acute Cyclo toxicity

The Banff classification Conclusion The Banff classification has proposed a schema for interpretation and gradation of the histological findings in renal allograft biopsies that can be used as an indication for therapeutic consequences and expected graft survival.