IPLab:Lab 6:Chronic Rejection

Clinical Summary

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.

Surgical Pathology Findings

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

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 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.
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.
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.
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).
This is a photomicrograph of rejected kidney with a focus of cellular infiltrate (left) 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 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.
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).