Case 5 Helmut Hopfer Institute of Pathology, University Hospital Basel

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Presentation transcript:

Case 5 Helmut Hopfer Institute of Pathology, University Hospital Basel

Pathological diagnosis transplant kidney (biopsy): diffuse acute interstitial cellular rejection

Clinical history 37 year old women Unknown basic disease Deceased donor kidney transplantation 6 months prior to biopsy 3 HLA-mismatches, 2 donor-specific antibodies, negative B- and T-cell cross match → induction therapy with ATG-Fresenius and IVIG Maintenance immunosuppression with tacrolimus, mycophenolalte mofetil (MMF), steroids

Clinical course *1 antibody-mediated rejection (3 weeks) *2 polyomavirus nephro-pathy (12 weeks)

Differential diagnosis PVN progression PVN resolution Concurrent interstitial cellular rejection Combination

SV40 immunohistochemistry No cytopathic effect SV40 positive cells in cortex and medulla

PVN progression stage: A B C

PVN resolution Blood Kidney time after transplantation PVN resolving PVN residual PVN BK dynamics increasing decreasing cleared distinction ICR? impossible impossible? rejection therapy? no yes, if clinical BK-specific immunity viruria viremia BK-induced tubular damage BK-induced inflammation anti-BK inflammation and IEL

Diagnosis Resolving polyomavirus nephropathy Schaub et al., Neph Dial Transplant 22:2386-2390,2007

Follow up

BK-specific immune response BK-specific humoral immune response BK-specific cellular immune response after clearance Schaub et al., Neph Dial Transplant 22:2386-2390,2007

Take-home messages If you think of acute interstitial cellular rejection in the context of PVN, think: anti-BK acute interstitial nephritis (resolving PVN) Clinicopathological correlation is key to correct biopsy interpretation