Difference between revisions of "IPLab:Lab 6:Chronic Rejection"

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== Clinical Summary ==
 
== Clinical Summary ==
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This 39-year-old male had malignant hypertension with malignant nephrosclerosis, progressing to chronic renal failure. He underwent a bilateral nephrectomy for control of his hypertension and received a cadaveric renal transplant. He did well, although he developed diabetes mellitus and had persistent, but less severe controllable hypertension. Two years following transplantation he was admitted to the hospital for control of his hypertension and evaluation of his chronic rejection. Initial blood pressure while in the hospital was in the range of 160/110 to 160/100 mm Hg. He was placed on a more intensive hypertension regimen, and he gradually became normotensive. He received one hemodialysis treatment prior to discharge. At the time of discharge, his blood pressure was 100 to 110 over 60 to 70 and he was doing well on dialysis. His BUN was 113 mg/dL and creatinine 5.2 mg/dL, and he had a hematocrit (PCV) of 27%. The patient was again admitted one month later for evaluation of azotemia and for control of his hypertension. It was felt that his chronic rejection was end-stage and that he would have to be dialyzed periodically. He was put on a renal failure diet, and over the period of his hospitalization, his BUN and creatinine finally stabilized at high levels. He tolerated dialysis well, and a transplant nephrectomy was done at 2 1/2 years post transplant. At the time of discharge, the patient's BUN was 78 mg/dL, creatinine 3.6 mg/dL, WBC 5000 cells/mm³, and the PCV was 26%.
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This 39-year-old male had malignant hypertension with malignant nephrosclerosis, progressing to chronic renal failure. He underwent a bilateral nephrectomy for control of his hypertension and received a cadaveric renal transplant. He did well, although his bllod pressure was elevated and his BUN and creatinine were gradually rising despite aggressive treatment. A transplant nephrectomy was performed 4 years after his transplant and he resumed hemodialysis.  
  
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== Surgical Pathology Findings ==
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The kidney weighed 125 grams and was covered by a thick capsule, which was partially adherent to the cortex, but could be stripped from the kidney with slight difficulty. The cortex was thinned but calyces and pelvis of the kidney appeared normal. The vessels were not prominent. The renal arteries and vein appeared normal.
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The kidney weighed 215 grams and was covered by a thick capsule, which was partially adherent to the cortex, but could be stripped from the kidney with slight difficulty. The calyces and pelvis of the kidney appeared normal. The vessels were not prominent. The renal arteries and vein appeared normal.  
 
  
 
== Images ==
 
== Images ==
 
<gallery height="250px" widths="250px">
 
<gallery height="250px" widths="250px">
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File:IPLab6ChronicRejection1.jpg|This is a low-power photomicrograph of the kidney from this case of chronic transplant rejection. Note the focal areas of hemorrhage and inflammatory cell infiltrate in this section.  
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File:IPLab6ChronicRejection1b.jpg|This is a low-power photomicrograph of the kidney from this case of chronic transplant rejection. Note the focal areas of hemorrhage and inflammatory cell infiltrate in this section.  
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File:IPLab6ChronicRejection2.jpg|This is a higher-power photomicrograph of kidney containing a section of blood vessel that demonstrates a marked neointimal proliferative response (1). In this case the lumen of the artery is obliterated. Also note the cellular infiltrate in the interstitium of the kidney (2) and the paucity of tubules.
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File:IPLab6ChronicRejection2b.jpg|This is a photomicrograph of kidney with congestion and sclerosis of the glomeruli. Note that there is a marked loss of renal tubules throughout this section with replacement by fibrous connective tissue. Also note the cellularity of the glomeruli.  
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File:IPLab6ChronicRejection3.jpg|This is a photomicrograph of kidney with a focal area of hemorrhage around a small blood vessel (left) and congestion of the glomeruli. Note that there is a marked loss of renal tubules throughout this section with replacement by fibrous connective tissue. Also note the cellularity of the glomeruli.  
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File:IPLab6ChronicRejection3b.jpg|This is another area of renal cortex similar to the previous image. Note the fibrosis and loss of renal tubules throughout this section.
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File:IPLab6ChronicRejection4.jpg|This is another area of renal cortex similar to the previous image. Note the fibrosis (1) and loss of renal tubules throughout this section. Also note the focus of inflammatory cells (2) indicating that despite the chromic nature of this lesion, there is still ongoing active rejection and renal damage.
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File:IPLab6ChronicRejection4b.jpg|This high-power photomicrograph of glomeruli from this kidney demonstrating increased cellularity with mesangial expansion (arrows). There is generalized loss of tubules and replacement by fibrosis in this section (1)  
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File:IPLab6ChronicRejection5.jpg|This high-power photomicrograph of glomeruli from this kidney demonstrates congestion (1), increased cellularity of glomeruli with mesangial expansion, and a glomerulus that is almost completely obliterated or sclerosed (2).
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File:IPLab6ChronicRejection5b.jpg|This is a photomicrograph of rejected kidney with cellular infiltrates and a small artery with neointimal proliferation and stenosis (arrow).
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File:IPLab6ChronicRejection6.jpg|This is a photomicrograph of rejected kidney with a focus of cellular infiltrate (left) and a small artery with neointimal proliferation and stenosis (arrow).  
 
 
File:IPLab6ChronicRejection7.jpg|This is a photomicrograph of a glomerulus with a mild cellular infiltrate (left) and a small damaged glomerulus (right). There is extensive interstitial fibrosis (1), loss of renal tubules, and the remaining tubules contain protein (2) indicating severe damage.  
 
File:IPLab6ChronicRejection7.jpg|This is a photomicrograph of a glomerulus with a mild cellular infiltrate (left) and a small damaged glomerulus (right). There is extensive interstitial fibrosis (1), loss of renal tubules, and the remaining tubules contain protein (2) indicating severe damage.  
 
File:IPLab6ChronicRejection8.jpg|This is a high-power photomicrograph of renal cortex with cellular infiltrate and few remaining renal tubules. The cellular infiltrate comprises macrophages, activated (large) lymphocytes and a few neutrophils and plasma cells.  
 
File:IPLab6ChronicRejection8.jpg|This is a high-power photomicrograph of renal cortex with cellular infiltrate and few remaining renal tubules. The cellular infiltrate comprises macrophages, activated (large) lymphocytes and a few neutrophils and plasma cells.  
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File:IPLab6ChronicRejection9.jpg|This is a high-power photomicrograph of a damaged glomerulus. Note the loss of normal capillary structure, the mesangial expansion and the infiltration of large mononuclear cells.  
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File:IPLab6ChronicRejection9b.jpg|This high-power photomicrograph demonstrates the characteristic manifestations of chronic antibody-mediated rejection. The glomerulus shows inflammatory cells within the capillary loops (glomeruliitis), accumulation of mesangial matrix, and duplication (or multilamination) of the capillary basement membrane (arrow). 
 
File:IPLab6ChronicRejection10.jpg|This is a high-power photomicrograph of a kidney from another case of chronic transplant rejection. In this case there is extensive damage to the kidney due to the chronic rejection (loss of tubules and glomerular lesions). In addition, this kidney was removed during an episode of acute rejection. The marked cellular infiltrate indicates acute rejection in a case of chronic transplant rejection.  
 
File:IPLab6ChronicRejection10.jpg|This is a high-power photomicrograph of a kidney from another case of chronic transplant rejection. In this case there is extensive damage to the kidney due to the chronic rejection (loss of tubules and glomerular lesions). In addition, this kidney was removed during an episode of acute rejection. The marked cellular infiltrate indicates acute rejection in a case of chronic transplant rejection.  
 
File:IPLab6ChronicRejection11.jpg|This is a higher-power photomicrograph of kidney from the previous image demonstrating the cellular infiltrate which is comprised of lymphocytes, macrophages, plasma cells and a few neutrophils.  
 
File:IPLab6ChronicRejection11.jpg|This is a higher-power photomicrograph of kidney from the previous image demonstrating the cellular infiltrate which is comprised of lymphocytes, macrophages, plasma cells and a few neutrophils.  
 
File:IPLab6ChronicRejection12.jpg|Photomicrograph from another region of previous image. Note the cellular infiltrate around a small blood vessel (right) and neutrophils within renal tubules (arrow).  
 
File:IPLab6ChronicRejection12.jpg|Photomicrograph from another region of previous image. Note the cellular infiltrate around a small blood vessel (right) and neutrophils within renal tubules (arrow).  
 
</gallery>
 
</gallery>
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== Virtual Microscopy ==
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<peir-vm>IPLab6ChronicRejection</peir-vm>
  
 
== Study Questions ==
 
== Study Questions ==
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=== Images ===
 
=== Images ===
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* [http://peir.path.uab.edu/library/index.php?/tags/2146-rejection PEIR Digital Library: Rejection Images]
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* [{{SERVER}}/library/index.php?/tags/2146-rejection PEIR Digital Library: Rejection Images]
 
* [http://library.med.utah.edu/WebPath/IMMHTML/IMMIDX.html#4 WebPath: Transplant Rejection]
 
* [http://library.med.utah.edu/WebPath/IMMHTML/IMMIDX.html#4 WebPath: Transplant Rejection]
  

Latest revision as of 00:08, 9 July 2020

Clinical Summary[edit]

This 39-year-old male had malignant hypertension with malignant nephrosclerosis, progressing to chronic renal failure. He underwent a bilateral nephrectomy for control of his hypertension and received a cadaveric renal transplant. He did well, although his bllod pressure was elevated and his BUN and creatinine were gradually rising despite aggressive treatment. A transplant nephrectomy was performed 4 years after his transplant and he resumed hemodialysis.

The kidney weighed 125 grams and was covered by a thick capsule, which was partially adherent to the cortex, but could be stripped from the kidney with slight difficulty. The cortex was thinned but calyces and pelvis of the kidney appeared normal. The vessels were not prominent. The renal arteries and vein appeared normal.

Images[edit]

  • This is a low-power photomicrograph of the kidney from this case of chronic transplant rejection. Note the focal areas of hemorrhage and inflammatory cell infiltrate in this section.

  • This is a photomicrograph of kidney with congestion and sclerosis of the glomeruli. Note that there is a marked loss of renal tubules throughout this section with replacement by fibrous connective tissue. Also note the cellularity of the glomeruli.

  • This is another area of renal cortex similar to the previous image. Note the fibrosis and loss of renal tubules throughout this section.

  • This high-power photomicrograph of glomeruli from this kidney demonstrating increased cellularity with mesangial expansion (arrows). There is generalized loss of tubules and replacement by fibrosis in this section (1)

  • This is a photomicrograph of rejected kidney with cellular infiltrates and a small artery with neointimal proliferation and stenosis (arrow).

  • This is a photomicrograph of a glomerulus with a mild cellular infiltrate (left) and a small damaged glomerulus (right). There is extensive interstitial fibrosis (1), loss of renal tubules, and the remaining tubules contain protein (2) indicating severe damage.

  • This is a high-power photomicrograph of renal cortex with cellular infiltrate and few remaining renal tubules. The cellular infiltrate comprises macrophages, activated (large) lymphocytes and a few neutrophils and plasma cells.

  • This high-power photomicrograph demonstrates the characteristic manifestations of chronic antibody-mediated rejection. The glomerulus shows inflammatory cells within the capillary loops (glomeruliitis), accumulation of mesangial matrix, and duplication (or multilamination) of the capillary basement membrane (arrow). 

  • This is a high-power photomicrograph of a kidney from another case of chronic transplant rejection. In this case there is extensive damage to the kidney due to the chronic rejection (loss of tubules and glomerular lesions). In addition, this kidney was removed during an episode of acute rejection. The marked cellular infiltrate indicates acute rejection in a case of chronic transplant rejection.

  • This is a higher-power photomicrograph of kidney from the previous image demonstrating the cellular infiltrate which is comprised of lymphocytes, macrophages, plasma cells and a few neutrophils.

  • Photomicrograph from another region of previous image. Note the cellular infiltrate around a small blood vessel (right) and neutrophils within renal tubules (arrow).

Virtual Microscopy[edit]

Study Questions[edit]


Additional Resources[edit]

Reference[edit]

Journal Articles[edit]

Images[edit]

Related IPLab Cases[edit]

Lab 6: Immunopathology

Hypertension which has caused end-organ damage is termed malignant. Without proper treatment, these patients will usually die in less than 2 years. Blood pressures in patients with malignant hypertension are frequently 160/110 mm Hg or greater.

Renal failure is the severe reduction of renal function and often leads to reduced urinary output.

These tests are measures of kidney function. High levels mean low function.

A normal gamma-glutamyl transpeptidase (GGT) is 0 to 65 U/L.

An infiltrate is an accumulation of cells in the lung parenchyma--this is a sign of pneumonia.

An infiltrate is an accumulation of cells in the lung parenchyma--this is a sign of pneumonia.

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