1. U07-394 #171408800 Cad Tx 15 years ago Recent  creatinine with mild proteinuria No RAS

2. DOB 28-2-74 Hydronephrosis and hydroureter identified in neonatal period 2° to posterior urethral valves. Right nephrectomy. Ileal conduit created.

3. 1979: 1 st kidney transplant – early rejection 1983: back on dialysis 1984: 2 nd transplant – early rejection with subsequent renal failure – not returned to dialysis! 1986: 3 rd transplant March 1995: Biopsy IgA, creat 500 – PD started 1997: October –4 th transplant –On prednisone, cellcept, tacrolimus –Base creatinine 130 –Persistant enterococus UTI –Creatinine unstable over several years 2002 serum creatinine settled down about 160

4. 2006: –slow progressive rise in creatinine to 250 with mild proteinuria and hypertension –MRA did not show RAS –Kidney biopsy done

5. IF IgG- Moderate linear GBM staining. IgA- Moderate mesangial staining. IgM- Mild mesangial staining with some granular extension to peripheral capillary loops. C3- Moderate vascular staining. Mild mesangial staining. C1q- Negative. Kappa- Negative. Lambda- Mild to moderate mesangial staining. Fibrinogen- Mild to moderate interstitial staining. Mild to moderate mesangial staining. Albumin- Moderate hyaline droplet change in tubular cytoplasm.

6. IgG

7. IgA

8. IgM

9. C3

11. Lambda

12. Fibrin

14. Albumin

15. IF C4d: Strong linear peritubular capillary staining

16. C4d

17. EM Will be ready next week

18. Diagnosis Renal Biopsy: Chronic active Ab-mediated rejection with chronic transplant glomerulopathy with a background of IgA nephropathy and anti- GBM Ab disease, both being documented by IF findings C4d is positive and Ab-mediated rejection is likely to be the most important of the 3 disease entities present Banff scores: –G0 CG2 I2 CI1 T1 CT1 V0 CV1 AH3 MM2 PTC3

19. Comment 3 concurrent diseases Impossible to say with certainty which is the predominant disease process Ab-mediated damage appears quite important: –aggregates of cells in PTC –chronic tg –C4d+ and may likely be the predominant process.