slide seminar - ii pathology of renal transplant

Click here to load reader

Post on 11-Jan-2016

63 views

Category:

Documents

0 download

Embed Size (px)

DESCRIPTION

Lorraine Racusen Prof. of Pathology Johns Hopkins Medical School Baltimore, MD. R.K. Gupta Prof & Head Department of Pathology SGPGIMS, Lucknow India. Slide Seminar - II Pathology of Renal Transplant. Slide Seminar- II Pathology of Renal Transplant L Racusen & RK Gupta. - PowerPoint PPT Presentation

TRANSCRIPT

International CME on Renal Pathology 14th - 16th March, 2005 International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
R.K. Gupta Professor & Head Department of Pathology SGPGIMS, Lucknow, India
Department of Pathology Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow- 226014, INDIA
US Coordinator:
Surya V. Seshan Professor of Pathology Chief, Renal Pathology Weill Medical College of Cornell University New York, NY
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Pathology of Renal Transplant
L Racusen & RK Gupta
Case 1: 38 years male, 2 yrs post renal transplant biopsy
Case 2: 65 years female, 9 days post renal transplant biopsy
Case 3: 34 years female, 3.2 years post renal transplant with H/O UTI &…
Case 4: 58 yrs male, 6 month post-transplant with colonic perforation
Case 5: 31 Yrs male, 4 yrs post-transplant with duodenojejunal mass
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Case 1
38 year old man status post renal transplant 2-3 years before biopsy.
Original disease was Alport’s syndrome, complicated by hypertension.
Presented with palpitations, and was found to have a creatinine of 4.9 mg%. With hydration, his creatinine only fell to 4.1 mg%.
He was biopsied to rule out rejection and other processes in the allograft, and to assess for chronic changes.
There are a variety of processes in this allograft – please identify.
What is the prognosis in the short-term? The long-term?
What special concern is there in a transplant patient with this underlying disease?
Slide Seminar- II: Pathology of Renal Transplant - Case 1
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Case 1
The biopsy reveals acute rejection, with mild intimal arteritis (v1), Banff type 2A, with a severe tubulointerstitial component (i3, t3). Focal leukocyte margination is noted in glomeruli and peritubular capillaries, mononuclear with occasional neutrophils. Though difficult to assess, chronic changes are significant (ci2-3, ct2-3).
Immunofluorescence reveals diffuse though mild linear capillary staining for C4d – R/O anti-donor antibody.
The patient had been previously treated with OKT3, and had developed anti-OKT3 antibodies, so he was treated with thymoglobulin. There was poor response to therapy, and the patient returned to dialysis within months with a failed allograft.
Slide Seminar- II: Pathology of Renal Transplant - Case 1
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Go to Case Index
In the setting of Banff type 2 rejection, a severe tubulointerstitial component predicts relative resistance to treatment short-term; the same study also demonstrated worse outcome with type 2B than with type 2A rejection, reinforcing the importance of making this distinction on allograft biopsy.
The staining for C4d is diffuse, but only mild, with staining done on frozen tissue using the monoclonal antibody for C4d; the requirement for a positive reading using this technique is for strong staining, so this should be interpreted as below threshold. However, anti-donor antibody should be sought, to rule out an antibody-mediated component. The quite extensive chronic changes portend a poorer long-term (and in this case short-term!) outcome.
Slide Seminar- II: Pathology of Renal Transplant - Case 1
Case 1
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
References:
Haas M, Kraus ES, Samaniego-Picota M, et al, Acute renal allograft rejection with intimal arteritis: histologic predictors of response to therapy and graft survival. Kidney Int 61:1516-26, 2002
Racusen LC, Solez K, Colvin RB, et al, The Banff 97 working classification of renal allograft pathology. Kidney Int 55:713-723, 1999
Racusen LC, Solez K, Colvin R. Fibrosis and atrophy in the renal allograft – Interim report and new directions. Am J Transplant 2:203-6, 2002
Racusen LC, Halloran PF, Solez K. Banff 2003 meeting report: new diagnostic insights and standards. Am J Transplant 4:1562-6, 2004
Case 1
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Go to Case Index
65 year old female had a history of chronic interstitial nephritis and was on dialysis.
She received a living related renal transplant from her daughter 9 days prior to biopsy.
The patient has developed a rise in creatinine after improving function post-operatively.
A biopsy is performed to rule out rejection. What is you diagnosis? Indicate possible underlying etiologies.
Case 2
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Extensive tubulo-toxic change
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
The biopsy reveals acute rejection, vascular type, with moderate-to-severe intimal arteries (v2), Banff type 2B, with no significant tubulointerstitial component (i0, t0).
A total of 4 small arteries have intimal arteritis, of varying severity.
There is significant and extensive isometric vacuolization of tubular cells – R/O drug toxicity.
No chronic changes are seen.
There is minimal C4d staining in peritubular capillaries.
She was begun on steroids and thymoglobulin for the rejection; the dose of thymoglobulin had to be decreased due to pancytopenia.
Creatinine fell to 0.9 mg%, then stabilized at 1-1.3 mg%.
Slide Seminar- II: Pathology of Renal Transplant - Case 2
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Reference:
Racusen LC, Solez K, Colvin RB, et al, The Banff 97 working classification of renal allograft pathology. Kidney Int 55:713-723, 1999
Slide Seminar- II: Pathology of Renal Transplant - Case 2
Case 2
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Go to Case Index
34 year old female S/P deceased donor renal transplant 3.2 years prior to biopsy. The cause of end-stage renal disease is unknown.
She now presents with a rise in creatnine from 1.9 to 2.9 mg%. She has multiple leukocytes in the urine, and history of recent urinary tract infection.
There is some concern that the patient has been non-compliant with her medications. Indicate your diagnosis/diagnoses.
Case 3
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Membranous glomerulonephritis
Case 3
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
The biopsy reveals acute cell-mediated rejection, moderate-to-severe tubulointerstitial type, Banff type IB, with focally severe tubulitis (t3). In addition, there was an area in the cortex with numerous peritubular and intratubular neutrophils, consistent with bacterial infection. In addition, glomeruli show mild increase in mesangial matrix, with very mild glomerulitis (g0-1). While difficult to assess, there appear to be mild-to-moderate chronic changes (ci1-2, ct1-2).
Immunofluorescence studies reveal no C4d staining in peritubular capillaries. However, there is diffuse granular capillary staining for IgG (2-3+), IgM (trace-1+), C3 (1+) and kappa and lambda light chains (2-3+), and C4d (2-3+).
Electron Microscopy reveals subepithelial dense deposits, confirming a diagnosis of early membranous glomerulopathy. Presumably this is a de novo disease, thought the cause of the patient’s end-stage renal disease is unclear.
Membranous glomerulopathy in the allograft may impinge on graft survival, but not invariably.
Pyelonephritis in grafts is not rare – if occurring within the first 3 months, it impacts on graft survival.
Slide Seminar- II: Pathology of Renal Transplant - Case 3
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Racusen LC, et al, Banff 97 (see above)
Denton MD, Singh AK. Recurrent and de novo glomerulonephritis in the renal allograft. Semin Nephrol 20:164-75. 2000
Hariharan S. Long-term kidney transplant survival. Am J Kidney Dis 38:S44-50, 2001
Seikaly MG. Recurrence of primary disease in children after renal transplantation. Ped Transplant 8:113, 2004
Giral et al, Acute graft pyelonephrits and long-term kidney graft outcome. Kidney Int 61:1880, 2002
Slide Seminar- II: Pathology of Renal Transplant - Case 3
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Presented with facial swelling, raised S. creatinine, UTI and sinusitis
Cald well luck surgery performed
Post operative patient developed acute abdominal pain,
X-ray abdomen showed gas under diaphragm and a diagnosis of intestinal perforation was made
Exploratory laprotomy done and colonic perforation repaired
Tissue from maxillary sinus and Colonic resection margins for histopathology
Case 4
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Maxillary Sinus
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Maxillary Sinus
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Slide Seminar- II: Pathology of Renal Transplant - Case 4
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Non-parallel walls
Follow-up
Beginning
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Classification:
Morphology:
Broad, twisted, aseptate ribbon like hyphae, branching at right angles, size: 5 - 25 micron
Special stains:
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Fungal infection is an uncommon complication after renal transplantation
Mucormycosis is rare fungal infection in immuno-suppressed patient (Approx 4% in post renal Tx)
Common clinical presentations- Cerebral, sino-pulmonary, GIT, Kidney, disseminated and cutaneous
Local area necrosis and angioinvasion
Fatal out come in majority of cases
A high index of suspicion, leading to early diagnosis and initiation of antifungal treatment, in addition to early surgery, are keys to a more favorable outcome.
Slide Seminar- II: Pathology of Renal Transplant - Case 4
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
References:
Chkhotua A, Yussim A, Tovar A, etal Mucormycosis of the renal allograft: case report and review of the literature. Transpl Int. 2001 Dec;14(6):438-41.
Jha V, Chugh KS. Posttransplant infections in the tropical countries. Artif. Organs 2002: 26 (9): 770- 7.
Reis MA, Costa RS, Ferraz AS. Causes of death in renal transplant recipients: a study of 102 autopsies from 1968 to 1991. J R Soc Med. 1995 Jan;88(1):24-7.
Bakshi NA, Volk EE. Pulmonary mucormycosis diagnosed by fine needle aspiration cytology. A case report.Acta Cytol. 2001 May-Jun;45(3):411-4.
Slide Seminar- II: Pathology of Renal Transplant - Case 4
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Presented with gastric outlet obstruction
Upper GI endoscopy revealed narrowing of duodeno-jejunal junction
CT scan showed mass in D3 and D4 and proximal jejunum
Operative findings - large well encapsulated mass in DJ region
Resected loop of jejunum with mass for histopathology
Case 5
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Gross:
A large irregular greyish white fleshy and friable mass with areas of haemorrhage, measuring 11x8x4cm involving 9 cm length of the jejunum.
Mesentric fat showed haemorrhage with whitish areas.
No lymph nodes were found.
Slide Seminar- II: Pathology of Renal Transplant - Case 5
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
Last Viewed Slide
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
End Show
End
Slide
Show
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Ulcerated mucosa with dense diffuse infiltration by predominantly intermediate sized atypical lymphoid cells displaying round to irregular nuclear contours with clumped chromatin, inconspicuous nucleoli and scant to moderate amount of cytoplasm.
Tumor was extensively present in the lamina propria
Tumor was infiltrating transmurally upto the serosa.
At places large atypical lymphoid cells with bizarre hyperchromatic nuclei and focal lymphoplasmacytoid cells were also seen.
Brisk mitotic activity present
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Occuring after solid organ and bone marrow transplantation.
Variable clinical and histopathological spectrum.
Scarce data on live related renal allograft recipients.
Incidence:
0.5 to 2.55 % in renal transplant recipients.
2.2-10 % heart, lung and heart-lung transplant recipient.
Slide Seminar- II: Pathology of Renal Transplant - Case 5
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Slide Seminar- II: Pathology of Renal Transplant - Case 5
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Early Lesions
centroblastic / immunoblastic
Anaplastic large cell lymphomas (T or null)
Others
Plasmacytoma like, T-cell rich / Hodgkins disease like B cell PTLD
Slide Seminar- II: Pathology of Renal Transplant - Case 5
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
Case 5
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide
References:
Nalesnik MA, Jaffe R, Starlz TE, Demetris AJ, Porter K, Burnham JA etal. The pathology of posttransplant lymphoproliferative disorder occurring in the setting of cyclosporine A- prednisolone immunosuppression. Am J of Pathol 1988; 133(1): 173-92.
Harris NL, Jafe ES, Stein H, et al. A revised European-American classification of lymphoid neoplasms. A proposal from the international lymphoma study group. Blood 1994; 84: 1361-92.
Swerdlow SH. Classification of post transplant lymphoproliferative disorders: from the past to the present. Semin Diag Pathol 1997; 14(1): 2-7.
Bates WD, Gray DW, Dada MA, Chetty R, Gatter KC, Davies DR etal. Lymphoproliferative disorders in Oxford renal transplant patients. J Clin Pathol 2003; 56(6): 439-46.
Opelz G, Dohler B. Lymhpoma after solid organ transplantation: a collaborative transplant study report. Am J Transplant 2004; 4: 222-30.
Maniyur R, Anant K, Aneesh S, Vinita E, Manoj J, Rakesh P. Posttransplant epididymal lymphoma: an aggressive variant. Transplantation 2003; 75(2): 246-7.
Slide Seminar- II: Pathology of Renal Transplant - Case 5
DIAGNOSIS & DISCUSSION
International CME on Renal Pathology, Department of Pathology , SGPGI, Lucknow, INDIA
Last Viewed Slide