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)

U04-22639

#897870100

• Native kidney

• 64 y.o. female with Cr 188, 3+ hemoglobinuria, about 300 g proteinuria

• Vasculitic work-up negative

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.

IgG

IgM

C3

Kappa

Fibrin

Albumin

DiagnosisRenal Biopsy:

• Focal proliferative immune complex glomerulonephritis progressing toward chronic glomerulonephritis.

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)

U06-21732

#897870100

• LRD Tx

DiagnosisRenal Biopsy (at time of implantation):

• No specific diagnostic findings

• Minimal arteriosclerotic vascular changes

Hospital Course:

• Excellent/ immediate post-op kidney function.

• Hypotension and low Hgb: 3 units PRBC• Immunosuppression:1. Belatacept (Belatacept benefit study)2. Prednisone3. MMF• Meds on discharge: Crestor, Valganciclovir,

Replavite, Losec, MMF, Prednisone, Benefit008 study drug, phosphate, senokot, Fragmin.

• Started on coumadin Nov 28th.

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

2nd.

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

Date: Creat:

Nov 14 215

Nov 17 100

Nov 30 97

Dec 1 120

Dec 6 162 (1st Bx)

Dec 11 192 (2nd Bx)

Dec 14 189

Kidney Biopsies

?

U06-23272

#897870100

• LRD Tx 14/11/06

• Creat 70 140 over several days

IF

• C4d- Negative.

EM

• Will follow in the coming weeks

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

U06-23805

#897870100

• LRD kid Tx 1 month ago

• Creat 70 200

• Previous biopsy 1 week ago

• Why blood in tubules ? With proteinuria

IF

• C4d- Negative.

EM

• Will follow in the coming weeks

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