1. Landing on the Moon at Last! New Pathologic Landscapes In Renal Transplantation with Lymphocyte-depleting Anti- Rejection Protocols. Kim Solez, M.D.

2. The Apollo moon landing of 1969 became the model for adventure and exploration for a generation.

3. A quarter century later in 1992 Cal Stiller called me about the first MMF biopsies: “Kim, Kim, It’s like landing on the moon! Like nothing you have ever seen before!” Calvin R. Stiller, M.D. Chair Canadian Medical Discoveries Fund Awarded the Order of Canada Established the Multi-Organ Transplant Service at UWO in London, Ontario Calvin R. Stiller, M.D. Chair Canadian Medical Discoveries Fund Awarded the Order of Canada Established the Multi-Organ Transplant Service at UWO in London, Ontario

4. Cal Stiller Directed Canadian Multicenter Trials of Cyclosporine Therapy in Renal Allografts in 1980s - A legendary figure in transplantation Cal Stiller Directed Canadian Multicenter Trials of Cyclosporine Therapy in Renal Allografts in 1980s - A legendary figure in transplantation In 1978, Dr. Cal Stiller, who was attending a transplant meeting in Rome, tried without success to meet the scientist who had discovered a promising new anti- rejection drug, to discuss testing it in London. It was raining as Stiller finally found a cab in St. Peter's Square. Nearby, standing in the downpour, was a very wet Swiss scientist, Jean F. Borel, discoverer of cyclosporine. They shared the taxi and when the trip was over, it was decided London would be the site of clinical trials of the new agent that was to save countless lives around the world.

5. Slide 5 Virtual Pathology Slide http://www.telepathology.dcu.ie/vps02. php3 http://www.telepathology.dcu.ie/vps02. php3 VPS Breast Needle Core Study (JMIR 2003) http://www.telepathology.dcu.ie/vps02. php3 http://www.telepathology.dcu.ie/vps02. php3 http://www.medicine.uiowa.edu/path ology/uarep_histopathology/ Virtual slidebox of histopathology http://www.medicine.uiowa.edu/path ology/uarep_histopathology/ Virtual slidebox of histopathology http://www.medicine.uiowa.edu/path ology/uarep_histopathology/ http://www.medicine.uiowa.edu/path ology/uarep_histopathology/ http://alf3.urz.unibas.ch/patho/pub/2 002-11.htm Human Pathology -- Volume 34, No. 10 (October 2003) -- pages 968-974 Katharina Glatz- Krieger, Dieter Glatz, Michael J. Mihatsch Virtual Slide: high quality demand, physical limitations and affordability. http://alf3.urz.unibas.ch/patho/pub/2 002-11.htm Human Pathology -- Volume 34, No. 10 (October 2003) -- pages 968-974 Katharina Glatz- Krieger, Dieter Glatz, Michael J. Mihatsch Virtual Slide: high quality demand, physical limitations and affordability. http://alf3.urz.unibas.ch/patho/pub/2 002-11.htm http://alf3.urz.unibas.ch/patho/pub/2 002-11.htm http://vmic.unibas.ch http://vmic.unibas.ch

6. Slide 6 The ScanScope System A Complete Virtual Microscopy System

7. The First MMF Biopsies from the University of Wisconsin Cal Stiller was wrong at that moment in 1992. There was nothing unique about the morphologic changes seen under the influence of MMF. His impression otherwise was due to his unfamiliarity with kidney sections embedded in plastic as opposed to the usual paraffin embedding.

8. Wrong at the time in 1992, but presaging events of the present. However in a more general sense his words presaged an inevitable outcome of the development of new anti-rejection agents: However in a more general sense his words presaged an inevitable outcome of the development of new anti-rejection agents: Eventually there will be compounds or strategies used which will profoundly alter the pathologic landscape and the rules for diagnosis of rejection, and such a major morphologic development may usher in a new clinical era of anti-rejection therapy.

9. And the situation now? So are we there yet? Have we landed on the moon? Recently several biopsies from lymphocyte depleting clinical trails have shown a picture of predominant infiltration by cells of macrophage monocyte lineage, behaving like rejection clinically but fulfilling none of the usual criteria for rejection which require lymphocytes in tubules and arteries. So perhaps indeed the rules are changing! So are we there yet? Have we landed on the moon? Recently several biopsies from lymphocyte depleting clinical trails have shown a picture of predominant infiltration by cells of macrophage monocyte lineage, behaving like rejection clinically but fulfilling none of the usual criteria for rejection which require lymphocytes in tubules and arteries. So perhaps indeed the rules are changing!

10. For the details …. You must be patient!

11. Assumptions The fluidity of the pathological landscape in the transplanted kidney seems to have been consistently underestimated, the psychological "some things never change" mindset of human beings seems to promote the erroneous view that some changes in the kidney are unidirectional and permanent until the end of time. Much persuasive evidence argues against this.

12. Slides from Roz Mannon, Alan Kirk These pictures were taken by their pathologist, David Kleiner, on 15 Alemtuzumab patients. They received Alemtuzumab alone (n=6), with rapa (n=2), or Infliximab and rapa (n=4) or with DSG and rapa (n=3).

13. Slide 13Methods All patients enrolled on Alemtuzumab (CAMPATH 1H) treatment All patients enrolled on Alemtuzumab (CAMPATH 1H) treatment All biopsies taken through day 100 All biopsies taken through day 100 BANFF 97 criteria used to grade rejections BANFF 97 criteria used to grade rejections Infiltrates immuno-phenotyped using antibodies against CD3, CD4, CD8, CD20, CD45, CD45RO, CD68, HLA-DR, perforin, granzyme B Infiltrates immuno-phenotyped using antibodies against CD3, CD4, CD8, CD20, CD45, CD45RO, CD68, HLA-DR, perforin, granzyme B

14. Slide 14 Results - Biopsies 53 total biopsies (52 needle bx, 1 wedge) 53 total biopsies (52 needle bx, 1 wedge) Adequacy: 32 adequate, 13 subopt, 8 inadeq Adequacy: 32 adequate, 13 subopt, 8 inadeq Glomeruli: mean 15 (0-45) Glomeruli: mean 15 (0-45) Arteries: mean 2 (0-7) Arteries: mean 2 (0-7)

15. Slide 15 Clinical/Histological Rejection 12/15 patients had an episode of increased Cr to at least 1.5x baseline in the first 100 days 12/15 patients had an episode of increased Cr to at least 1.5x baseline in the first 100 days Histologic correlation in 9 patients: Histologic correlation in 9 patients: 3 Borderline 3 Borderline 1 Grade IA 1 Grade IA 3 Grade IB 3 Grade IB 1 Grade IIA 1 Grade IIA 1 Grade IIB 1 Grade IIB

16. Slide 16 Day 0 Day 14 Day 21 HLA-DR Immunostaining Progression

17. Slide 17 Day 0Day 14 Day 22Day 21 Progression of CD68 Infiltration in Alemtuzumab Treated Recipients

18. Slide 18 Focal Macrophage Infiltrate Corresponds to Focal HLA-DR Expression CD68 HLA-DR

19. Slide 19 AR Alem CD3 CD68 HLADR Composite of Campath Rejection vs. Non-Depletional Rejection

20. Slide 20 Practical Implications for Classification ? Routine staining for CD68 Probably no formal change in classification until experience with this new type of rejection grows. Sharing of morphologic data as important as sharing of genomics data. ? Routine staining for CD68 Probably no formal change in classification until experience with this new type of rejection grows. Sharing of morphologic data as important as sharing of genomics data.