Figure 173

Biopsy showing rejection (panel A) and membranous changes (panel B) in a woman 8 months after transplantation. The patient initially had idiopathic membranous nephropathy that progressed to end-stage renal failure over 5 years. She subsequently received a cadaveric allograft but developed proteinuria and renal dysfunction after 8 months. The biopsy shows recurrent membranous disease, with thickened glomerular capillary loops (and spikes on a silver stain), and features of acute interstitial rejection, with a pronounced cellular infiltrate and tubulitis. Additional sections also showed evidence of chronic cyclosporine toxicity. In many patients, transplantation biopsies have features of several pathologic processes. Recurrent nephritis can be overlooked in a biopsy showing evidence of chronic rejection, cyclosporine toxicity, or both.

Renal biopsy with Immunofluorescence and electron microscopy

Cyclosporin A level

Urine microscopy and culture

24-h urine protein

Renal ultrasonography

Anti-glomerular basement membrane autoantibody and antineutrophil cytoplasm antibody Cytomegalovirus serology and viral antigen detection Hepatitis C virus serology and RNA detection

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