A 50 year-old male with unknown cause end-stage renal disease, and in hemodialysis from January 2006, underwent renal transplantation in May 2006 from a 54 year-old deceased donor; cause of death was hemorrhagic cerebrovascular disease; his history was relevant for blood systemic hypertension from several years ago and type II diabetes mellitus diagnosed several years previous to death (it is not knowed how many years ago and received treatment).
The intraoperative course was uncomplicated. Renal function was well in the first days but it increase at 7th post-transplantation day to 2.9 mg/dL; ultrasound demonstrated perirenal hematoma and in a surgical intervention a renal biopsy was done (Figures 1, 2, and 3). Renal function improved and the patient was discharged with a creatinine of 1.4 mg/dL. Immunosuppression included cyclosporin, mycophenolate, and prednisone. The patient has not presented hyperglycemia.
One post-transplantation year the patient newly present creatinine increase: 2.1 mg/dL and there was not steroid boluses response. In addition proteinuria was detected: 600 mg/dL, without hematuria. Ultrasound detected lymphocele without urinary obstruction and the patient underwent surgical correction of this alteration; in the procedure the kidney appeared macroscopically normal; a new renal biopsy was done (one post-transplantation year) (Figures 4, 5, 6, and 7)
See the images.
Figure 1. First post-transplantation biopsy. Left: H&E, X400; right: PAS, X400.
Figure 2. First post-transplantation biopsy. Left: Masson's trichrome stain, X400; right: methenamine silver stain, X400.
Figure 3. First post-transplantation biopsy. Left: H&E, X400; right: PAS, X200.
Figure 4. Second post-transplantation biopsy. Left and right: Masson's trichrome stain, X400.
Figure 5. Second post-transplantation biopsy. Left: Masson's trichrome stain, X400; right: methenamine silver stain, X400.
Figure 6. Second post-transplantation biopsy. Left and right: methenamine silver stain, X400.
Figure 7. Second post-transplantation biopsy. Immunofluorescence using antiserum to IgG, x400 (left) and C1q, x600 (right).
Immunofluorescence for IgM and C3: focal and segmental
What is your diagnosis?