Figure 172

Acute cellular rejection and cyclosporine toxicity usually can be distinguished easily from recurrent glomerular disease. Recurrent hemolytic uremic syndrome, however, can cause a microangiopathy similar to cyclosporine toxicity, with erythrocyte fragments visible both in blood films and within glomerular capillary loops. The major diagnostic difficulty lies with chronic rejection, especially in the form of transplantation glomerulopathy, and de novo or transplanted glomerulonephritis. Chronic transplantation glomerulopathy occurs in 4% of renal allografts and usually is associated with proteinuria of more than 1 g/d, beginning a few months after transplantation. Chronic glomerulopathy shares some features with both recurrent mesangiocapillary glomerulonephritis type I and hemolytic uremic syndrome: glomerular capillary wall thickening, mesangial expansion, and double contour patterns of the capillary walls with mesangial cell interposition [13]. Thus, a definitive diagnosis of recurrent nephritis may require histologic characterization of the underlying primary renal disease and a graft biopsy before transplantation.

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