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Diagnosis: Acute cellular rejection, type IIB, combined with changes suggestive of antibody-mediated rejection, and secondary thrombotic microangiopathy

The feautures of the arterial lesion on Figures 3 and 10, with near-obstruction of the lumen, indicate vascular lesion category v2, according to the Banff scoring scheme for renal allograft biopsy. This feature is a change of T-cell mediated acute rejection. In addition, thrombotic microangiopathy (Figures 6 - 9) and glomerulitis (Figures 4 and 9) are changes suggesting antibody-mediated rejection. C4d positivity (Figure 11) is another sign suggesting humoral rejection. Clinical presentation, with delayed graft function, and biopsy with these alterations only 6 post-transplantation days are features suggesting preformed anti-donor antibodies.

Combined T-cell mediated (cellular) and antibody-mediated (humoral) rejection is probably more common than recognized.

According to Banff scheme on renal allograft pathology, demonstration of anti-donor antibodies are necessary to confirm antibody-mediated rejection (Racusen et al, Am J Transplant 3:708-14, 2003. [PubMed link] [Free full text])

The patient was treated with rituximab and plasmapheresis and she is well several months later, with stable renal function: creatinine between 1.4 and 1.6 mg / dL.

See the chapter [Renal Transplantation Pathology] of our Tutorial (this chapter has only Spanish version).

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Bibliography

• Solez K, Colvin RB, Racusen LC, et al. Banff 07 classification of renal allograft pathology: updates and future directions. Am J Transplant. 2008;8:753-60. [PubMed link]
• Feucht HE, Mihatsch MJ. Diagnostic value of C4d in renal biopsies. Curr Opin Nephrol Hypertens. 2005;14:592-8. [PubMed link]

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