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Kidney non-tumor

Kidney transplantation

Acute rejection


Reviewers: Nikhil Sangle, M.D. (see Reviewers page)
Revised: 26 December 2012, last major update August 2012
Copyright: (c) 2003-2012, PathologyOutlines.com, Inc.

General
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● Can occur at any time after transplantation, although usually within months of transplant
● Either acute antibody mediated rejection (morphologic evidence of acute tissue injury, circulating donor-specific allo-antibodies, C4d+; variable cellular infiltrates) or acute cellular renal allograft rejection (infiltration of allograft by lymphocytes and other inflammatory cells)

Gross images
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Various images

Micro images
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Banff 97 classification


Acute antibody mediated rejection

General
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● Also called acute humoral rejection, acute tubulointerstitial rejection
● Associated with poor graft outcome

Micro description
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● Most severe changes are in small arteries, arterioles and veins
Vessels: early changes are neutrophil margination in peritubular interstitial capillaries, swelling and vacuolization of endothelial cells with ulceration, chronic inflammatory cells in intima and vacuolization of smooth muscle cells in media; thrombi are often small and non-occlusive, but in irreversible rejection, become obliterative and widespread with necrosis of vessel wall
Glomeruli: endothelial cell swelling, increased cellularity and occasional thrombosis
Tubules: focal necrosis
Interstitium: hemorrhage

Micro images
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Various images

Virtual slides
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Acute rejection

Immunofluorescence
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● Occasionally complement, IgM and IgG along with fibrin in vessel walls and glomeruli

Electron microscopy description
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● Endothelial cell swelling and separation of endothelium from basement membrane by fluffy fibrillar material, which may contain fibrin or platelet fragments


Acute cellular rejection

General
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● Most common form of rejection; T-lymphocyte mediated
● Usually reversible with therapy

Micro description
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Early: edema, lymphocytic infiltration of interstitium and peritubular capillaries (perivascular in very early stages) and dilation of peritubular capillaries
Late: tubulitis (lymphocytes on internal aspect of tubular basement membrane), increased infiltration by lymphocytes (60% CD8+), plasma cells, macrophages and mast cells, occasional granulocytes; tubulitis is more concentrated in cortex than medulla; phlebitis of arcuate and interlobular veins often present (Hum Pathol 2001;32:1388)

Micro images
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Various images

Immunofluorescence
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● Negative

Electron microscopy description
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● Tubular damage and regeneration, many inflammatory cells in interstitium
● Variable glomerular and vascular changes

Differential diagnosis
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● Urinary tract infection: neutrophilic tubulitis usually more severe than lymphocytic tubulitis, positive cultures


Acute vascular rejection

General
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● Intimal arteritis and transmural arteritis
● Usually mild; interstitial inflammation present, also peritublar capillaritis, usually transplant glomerulitis (Transplant Proc 2012;44:230)
● 40% have CD4d deposition, 25% have antibody mediated rejection
● Usually steroid resistant, requiring greater anti-rejection therapy

Micro images
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Various images

End of Kidney non-tumor > Kidney transplantation > Acute rejection

Ref Updated: 8/30/12


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