Case 5 Helmut Hopfer Institute of Pathology, University Hospital Basel

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Case 5Helmut HopferInstitute of Pathology,
University Hospital Basel
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Pathological diagnosis

• transplant kidney (biopsy)
• diffuse acute interstitial cellular rejection

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Clinical history

• 37 year old women
• Unknown basic disease
• Deceased donor kidney transplantation 6 months
  prior to biopsy
• 3 HLA-mismatches, 2 donor-specific antibodies,
  negative B- and T-cell cross match ? induction
  therapy with ATG-Fresenius and IVIG
• Maintenance immunosuppression with tacrolimus,
  mycophenolalte mofetil (MMF), steroids

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Clinical course
1 antibody-mediated rejection (3
weeks) 2 polyomavirus nephro-pathy (12 weeks)
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Differential diagnosis

• PVN progression
• PVN resolution
• Concurrent interstitial cellular rejection
• Combination

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SV40 immunohistochemistry

• No cytopathic effect
• SV40 positive cells in cortex and medulla

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PVN progression
B
stage A
C
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PVN resolution

Blood
Kidney
time after transplantation time after transplantation time after transplantation time after transplantation
PVN resolving PVN residual PVN
BK dynamics increasing decreasing cleared
distinction ICR? impossible impossible impossible?
rejection therapy? no no yes, if clinical
BK-specific immunity
viruria
viremia
BK-induced tubular damage
BK-induced inflammation
anti-BK inflammation and IEL
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Diagnosis

• Resolving polyomavirus nephropathy

Schaub et al., Neph Dial Transplant
222386-2390,2007
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Follow up
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BK-specific immune response
BK-specific humoral immune response
BK-specific cellular immune response
after clearance
Schaub et al., Neph Dial Transplant
222386-2390,2007
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Take-home messages

• If you think of acute interstitial cellular
  rejection in the context of PVN, think anti-BK
  acute interstitial nephritis (resolving PVN)
• Clinicopathological correlation is key to correct
  biopsy interpretation