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66 F

66 F. PMH: HTN, Gout, DVT (Feb/06 and ? Sep/06) PMH: Heterozygous for Prothrombin mutation. FOCAL PROLIFERATIVE IMMUNE COMPLEX GN (toward chronic GN)  Biopsy done in 2004, pANCA positive. On PD then switch to HD on May 2006 Medications on admission: Fragmin, Replavite, Crestor

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66 F

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  1. 66 F • PMH: HTN, Gout, DVT (Feb/06 and ? Sep/06) • PMH: Heterozygous for Prothrombin mutation. • FOCAL PROLIFERATIVE IMMUNE COMPLEX GN (toward chronic GN)  Biopsy done in 2004, pANCA positive. • On PD then switch to HD on May 2006 • Medications on admission: Fragmin, Replavite, Crestor • Living Related Kidney Transplant (14-Nov-06)

  2. U04-22639 #897870100 • Native kidney • 64 y.o. female with Cr 188, 3+ hemoglobinuria, about 300 g proteinuria • Vasculitic work-up negative

  3. IF • IgG- Minimal wipsy mesangial staining, looks just discernibly above background. • IgA-Negative. • IgM- Minimal to mild fine granular mesangial staining. • C3- Mild vascular and vascular pole staining. • C1q-Negative. • Kappa- Trace level fine granular mesangial staining. • Lambda-Negative. • Fibrinogen- Mild to moderate interstitial staining. • Albumin- Moderate background with mild hyaline droplet change in tubular cytoplasm.

  4. IgG

  5. IgM

  6. C3

  7. Kappa

  8. Fibrin

  9. Albumin

  10. DiagnosisRenal Biopsy: • Focal proliferative immune complex glomerulonephritis progressing toward chronic glomerulonephritis.

  11. Ms. CH 66 F • PMH: HTN, Gout, DVT (Feb/06 and ? Sep/06) • PMH: Heterozygous for Prothrombin mutation. • FOCAL PROLIFERATIVE IMMUNE COMPLEX GN (toward chronic GN)  Biopsy done in 2004, pANCA positive. • On PD then switch to HD on May 2006 • Medications on admission: Fragmin, Replavite, Crestor • Living Related Kidney Transplant (14-Nov-06)

  12. U06-21732 #897870100 • LRD Tx

  13. DiagnosisRenal Biopsy (at time of implantation): • No specific diagnostic findings • Minimal arteriosclerotic vascular changes

  14. Hospital Course: • Excellent/ immediate post-op kidney function. • Hypotension and low Hgb: 3 units PRBC • Immunosuppression: • Belatacept (Belatacept benefit study) • Prednisone • MMF • Meds on discharge: Crestor, Valganciclovir, Replavite, Losec, MMF, Prednisone, Benefit008 study drug, phosphate, senokot, Fragmin. • Started on coumadin Nov 28th.

  15. Creatinine started to rise Nov 28th. • Developed macroscopic hematuria Dec 2nd.

  16. Follow up Visits: Other work up: • LD, T. Bili, ALT: NL • P-ANCA + • PBS: NL • Hapto: Pending • Peak creatinine 204 µmol/L Dec 8th • Hem/Onc Consult on Dec 13th

  17. Kidney Biopsies ?

  18. U06-23272 #897870100 • LRD Tx 14/11/06 • Creat 70  140 over several days

  19. IF • C4d-Negative.

  20. EM • Will follow in the coming weeks

  21. DiagnosisRenal Biopsy (1 week post-Tx): • Tubular hemorrhage and injury • Further report to follow • Banff score: G0 I1 T1 V0 AH0 • Biopsy of marginal adequacy

  22. U06-23805 #897870100 • LRD kid Tx 1 month ago • Creat 70  200 • Previous biopsy 1 week ago • Why blood in tubules ? With proteinuria

  23. IF • C4d-Negative.

  24. EM • Will follow in the coming weeks

  25. DiagnosisRenal Biopsy (1 month post-transplantation) • Thrombotic microangiopathy of uncertain etiology • Banff score: G0 I1 T1 V0 AH0 • Further report to follow • Tubular hemorrhage, injury, and regenerative features

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