CASE 33 (November 2008)
The patient is a 36-year-old man. He developed end-stage renal disease at 34-year-old (unknown cause). After 7 months in hemodialysis he received a cadaveric-donor kidney. Renal function was good the first 8 post-transplantation months. At 9 months serum creatinine increased until 2.3 mg/dL. By ultrasound the graft kidney appear normal. By doppler there are not alterations in main graft vessels.
Immunosuppression: prednisone, cyclosporin, mycophenolate, without changes from the first post-transplantation week. There is not symptoms or clinical signs suggesting a infectious process or other features that explain the disfunction.
Hepatitis B and C viruses negative. Proteinuria: 210 mg/24h; erythrocytes: 3/CAP; no changes suggesting infection.
Acute rejection or cyclosporin toxicity were the presumptive diagnosis. A renal biopsy was undertaken.
Figure 1. H&E, X200.
Figure 2. H&E, X400.
Figure 3. H&E, X200.
Figure 4. H&E, seen with polarized light, X200.
Figure 5. H&E, seen with polarized light, X400.
Figure 6. Methenamine-silver stain, X400.
Figure 7. H&E, X400.
Immunohistochemistry for C4d: negative.
What is your diagnosis?