Case 63
With discussion
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CASE 63 (May 2011)

Clinical information

The patient is a 27-year-old woman who developed end-stage renal disease of unknown cause. After almost 2 years on peritoneal dialysis, she was transplanted from a 25-year-old deceased donor who died of traumatic brain injury. Immunosuppression with cyclosporine, prednisone and mycophenolate. Normal renal graft function during the first two years: creatinine between 0.9 and 1.2 mg/dL. Cyclosporine was switched to everolimus, due to gingival hyperplasia, 19 months post-transplant.

In a normal control 30 months after transplantation serum creatinine is 2.4 mg/dL. Asymptomatic patient, normal blood pressure.

Other laboratory tests: CBC: normal. Urinalysis: D: 1,012; Proteins: 75 mg/dL; erithrocytes: >30 hpf; leukocytes: 52 hpf; nitrites: negative; there is not report of casts. Urine culture: negative. Proteinuria 24 hours: 904 mg. Renal ultrasound: normal; resistance index: 0.8; increased echogenicity, the cortico-medullary differentiation is preserved. C3: 110 mg/dL (90-180); C4: 33,5 mg/dL (10-40).

A renal biopsy was performed. View the images.

Figure 1. H&E, X200.

Figure 2. H&E, X200.

Figure 3. PAS stain, X200.

Figure 4. H&E, X400.

Figure 5. Masson's trichrome stain, X400.

Figure 6. Masson's trichrome stain, X400.

Figure 7. Methenamine-silver stain, X400.

Figure 8. Methenamine-silver stain, X400

Figure 9. Methenamine-silver stain, X400.

Immunofluorescence staining for IgA, IgG, IgM, C3, C1q, kappa, and lambda: Negative.
Immunhistochemistry for C4d: Negative

What is your diagnosis?

See diagnosis and discussion