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'''Renal transplant pathology''' is grouped with the ''[[medical kidney diseases]]'', as this | '''Renal transplant pathology''', also '''kidney tranplant pathology''', is grouped with the ''[[medical kidney diseases]]'', as this usually precedes the transplant. Also, many renal transplants have recurrence of the pathology that lead to renal failure. | ||
=Rejection | =Rejection= | ||
There is a consensus on categories - known as "Banff 97". | |||
== | ==Overview== | ||
* | Allograft biopsy categories (Banff 97):<ref name=Ref_DARP400>{{Ref DARP|400}}</ref> | ||
*Mean graft survival is ~4 years for C4d+ interstitial capillaries vs. ~8 years for C4d- renal grafts.<ref name=pmid11135088>Impact of humoral alloreactivity early after transplantation on the long-term survival of renal allografts. Lederer SR, Kluth-Pepper B, Schneeberger H, Albert E, Land W, Feucht HE. Kidney Int. 2001 Jan;59(1):334-41. PMID 11135088.</ref> | {| class="wikitable" | ||
! Type | |||
! Key morphologic finding | |||
|- | |||
| Normal | |||
| no inflammation | |||
|- | |||
| Suspicious for acute rejection | |||
| focal mild tubulitis (1-4 mononuclear cells/tubular cross section) | |||
|- | |||
| Acute/active rejection | |||
| tubulitis (>4 mononuclear cells/tubular cross section); see separate table for grading | |||
|- | |||
| Chronic/sclerosing allograft nephropathy | |||
| interstitial fibrosis and tubular atrophy; see separate table for grading | |||
|} | |||
===Acute/active rejection=== | |||
Acute/active rejection in allograft biopsies (Banff 97):<ref name=Ref_DARP400>{{Ref DARP|400}}</ref> | |||
{| class="wikitable" | |||
! Grade | |||
! Key morphologic finding | |||
|- | |||
| IA | |||
| 4< mononuclear cell/tubular cross section ''or'' 10 tubular cells <10; >25% of parenchyma | |||
|- | |||
| IB | |||
| >10 mononuclear cell/tubular cross section ''or'' 10 tubular cells; >25% of parenchyma | |||
|- | |||
| IIA | |||
| mild-to-moderate intimal arteritis; <=25% of luminal area | |||
|- | |||
| IIB | |||
| severe intimal arteritis; >25% of luminal area | |||
|- | |||
| III | |||
| transmural arteritis and/or [[fibrinoid necrosis]] | |||
|} | |||
===Chronic/sclerosing allograft nephropathy=== | |||
Chronic rejection (Banff 97):<ref name=Ref_DARP400>{{Ref DARP|400}}</ref> | |||
{| class="wikitable" | |||
! Grade | |||
! Key morphologic finding | |||
|- | |||
| Grade 1 | |||
| mild interstitial fibrosis and tubular atrophy | |||
|- | |||
| Grade 2 | |||
| moderate interstitial fibrosis and tubular atrophy | |||
|- | |||
| Grade 3 | |||
| severe interstitial fibrosis and tubular atrophy | |||
|} | |||
==C4d staining== | |||
===General=== | |||
*Acute rejection associated with C4d staining.<ref name=pmid1747954>Vascular deposition of complement-split products in kidney allografts with cell-mediated rejection. Feucht HE, Felber E, Gokel MJ, Hillebrand G, Nattermann U, Brockmeyer C, Held E, Riethmüller G, Land W, Albert E. Clin Exp Immunol. 1991 Dec;86(3):464-70. PMID 1747954.</ref> | |||
*Mean graft survival is ~4 years for C4d +ve interstitial capillaries vs. ~8 years for C4d -ve renal grafts.<ref name=pmid11135088>Impact of humoral alloreactivity early after transplantation on the long-term survival of renal allografts. Lederer SR, Kluth-Pepper B, Schneeberger H, Albert E, Land W, Feucht HE. Kidney Int. 2001 Jan;59(1):334-41. PMID 11135088.</ref> | |||
===Microscopic=== | |||
Features:<ref>URL: [http://www.humpath.com/spip.php?article14451 http://www.humpath.com/spip.php?article14451]. Accessed on: 22 November 2011.</ref> | |||
*Diffuse cytoplasmic C4d staining of the peritubular capillaries. | |||
Image: | |||
*[http://www.humpath.com/spip.php?article14451 Positive C4d staining (humpath.com)]. | |||
==Acute rejection== | ==Acute rejection== | ||
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=Infection= | =Infection= | ||
==Polyomavirus== | ==Polyomavirus nephropathy== | ||
:See also: ''[[Urine_cytopathology#Human_polyomavirus_infection]]'' and ''[[Polyomavirus]]''. | |||
{{Main|Polyomavirus nephropathy}} | |||
=Transplant-related pathology= | =Transplant-related pathology= | ||
==Transplant glomerulopathy== | ==Transplant glomerulopathy== | ||
Microscopic: | *Abbreviated ''TG''. | ||
===General=== | |||
*Pathology that arises in the glomeruli of transplanted kidneys. | |||
*Considered to be a form of ''chronic antibody-mediated rejection''.<ref name=pmid21960169>{{Cite journal | last1 = Haas | first1 = M. | title = Transplant glomerulopathy: it's not always about chronic rejection. | journal = Kidney Int | volume = 80 | issue = 8 | pages = 801-3 | month = Oct | year = 2011 | doi = 10.1038/ki.2011.192 | PMID = 21960169 }}</ref> | |||
===Microscopic=== | |||
Features:<ref name=Ref_DARP411>{{Ref DARP|411}}</ref> | |||
*Irregular GBM thickening - '''key feature'''. | |||
*Tram-tracking of basement membrane. | *Tram-tracking of basement membrane. | ||
*Increased mesangial matrix. | |||
*Segmental and global glomerular sclerosis. | |||
DDx (tram-tracking): | DDx (tram-tracking):<ref name=pmid21960169/> | ||
*[[MPGN]]. | *[[MPGN]] (hepatitis C). | ||
*[[Thrombotic microangiopathy]] (TMA). | *[[Thrombotic microangiopathy]] (TMA). | ||
====Images==== | |||
<gallery> | |||
Image:Transplant_glomerulopathy_-_intermed_mag.jpg | Transplant glomerulopathy - intermed. mag. (WC/Nephron) | |||
Image:Transplant_glomerulopathy_-_high_mag.jpg | Transplant glomerulopathy - high mag. (WC/Nephron) | |||
Image:Transplant_glomerulopathy_-_very_high_mag.jpg | Transplant glomerulopathy - very high mag. (WC/Nephron) | |||
</gallery> | |||
==Chronic allograft nephropathy== | |||
*Abbreviated ''CAN''. | |||
*[[AKA]] ''chronic/sclerosing allograft nephropathy''. | |||
===General=== | |||
*Month-years post-transplant. | |||
*Gradual decline in graft function - typically with hypertension and hematuria.<ref name=pmid15954891>{{Cite journal | last1 = Joosten | first1 = SA. | last2 = Sijpkens | first2 = YW. | last3 = van Kooten | first3 = C. | last4 = Paul | first4 = LC. | title = Chronic renal allograft rejection: pathophysiologic considerations. | journal = Kidney Int | volume = 68 | issue = 1 | pages = 1-13 | month = Jul | year = 2005 | doi = 10.1111/j.1523-1755.2005.00376.x | PMID = 15954891 }} | |||
</ref> | |||
*Leading cause of chronic graft failure.<ref name=pmid10469349>{{Cite journal | last1 = Paul | first1 = LC. | title = Chronic allograft nephropathy: An update. | journal = Kidney Int | volume = 56 | issue = 3 | pages = 783-93 | month = Sep | year = 1999 | doi = 10.1046/j.1523-1755.1999.00611.x | PMID = 10469349 }}</ref> | |||
===Microscopic=== | |||
Features:<ref name=Ref_DARP411>{{Ref DARP|411}}</ref> | |||
*Arterial & arteriolar luminal narrowing - '''key feature'''. | |||
**Due to intimal and medial thickening. | |||
*Interstitial fibrosis and renal tubular atrophy. | |||
===Images=== | |||
<gallery> | |||
Image:Chronic_allograft_nephropathy_-_intermed_mag.jpg | CAN - intermed. mag. (WC/Nephron) | |||
</gallery> | |||
==Calcineurin-inhibitor toxicity== | ==Calcineurin-inhibitor toxicity== | ||
*Calcineurin-inhibitors (e.g. cyclosporine,<ref name=pmid10354295>{{cite journal |author=Zarifian A, Meleg-Smith S, O'donovan R, Tesi RJ, Batuman V |title=Cyclosporine-associated thrombotic microangiopathy in renal allografts |journal=Kidney Int. |volume=55 |issue=6 |pages=2457–66 |year=1999 |month=June |pmid=10354295 |doi=10.1046/j.1523-1755.1999.00492.x |url=}}</ref> | ===General=== | ||
*Calcineurin-inhibitors (e.g. cyclosporine,<ref name=pmid10354295>{{cite journal |author=Zarifian A, Meleg-Smith S, O'donovan R, Tesi RJ, Batuman V |title=Cyclosporine-associated thrombotic microangiopathy in renal allografts |journal=Kidney Int. |volume=55 |issue=6 |pages=2457–66 |year=1999 |month=June |pmid=10354295 |doi=10.1046/j.1523-1755.1999.00492.x |url=}}</ref> tacrolimus<ref name=Ref_FoRP203>{{Ref FoRP|203}}</ref>) toxicity can induce a [[thrombotic microangiopathy]]. | |||
===Microscopic=== | |||
Features: | |||
*Hyaline arteriopathy with a peripheral and nodular distribution (chronic toxicity). | *Hyaline arteriopathy with a peripheral and nodular distribution (chronic toxicity). | ||
*+/-Thrombotic microangiopathy - see ''[[Thrombotic_microangiopathy#Microscopic|microscopic for TMA]]''. | |||
=See also= | =See also= | ||
*[[Medical kidney diseases]]. | *[[Medical kidney diseases]]. | ||
*[[Kidney]]. | *[[Kidney]]. | ||
*[[Lung transplant pathology]]. | |||
*[[Heart transplant pathology]]. | |||
=References= | =References= |
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