Acute Tubular Necrosis

FIGURE 10-10 (see Color Plate)

Acute tubular necrosis in the allograft. Unlike "acute tubule necrosis" in native kidney, in this condition actual necrosis appears in the transplanted kidney but in a very small proportion of tubules, often less than one in 300 tubule cross sections. Where the necrosis does occur it tends to affect the entire tubule cross section, as in the center of this field [3].

FIGURE 10-11 (see Color Plate)

A completely necrotic tubule in the center of the picture in a case of acute tubular necrosis (ATN) in an allograft. The tubule is difficult to identify because, in contrast to the appearance in native kidney ATN, no residual tubular cells survive; the epithelium is 100% necrotic.

FIGURE 10-13
FIGURE 10-12 (see Color Plate)

Calcium oxalate crystals seen under polarized light. These are very characteristic of transplant acute tubular necrosis (ATN), probably because they relate to some degree to the duration of uremia, which is often much longer in transplant ATN (counting the period of uremia before transplantation) than in native ATN. With prolonged uremia elevation of plasma oxalate is greater and more persistent and consequently tissue deposition is greater [4].

FEATURES OF TRANSPLANT ACUTE TUBULAR NECROSIS (ATN) WHICH DIFFERENTIATE IT FROM NATIVE KIDNEY ATN

1. Apparently intact proximal tubular brush border

2. Occasional foci of necrosis of entire tubular cross sections

3. More extensive calcium oxalate deposition

4. Significantly fewer tubular casts

5. Significantly more interstitial inflammation

6. Less cell-to-cell variation in size and shape ("tubular cell unrest")

FIGURE 10-14

Calcium oxalate crystals seen by electron microscopy in transplant acute tubular necrosis.

Features of transplant acute tubular necrosis that differentiate it from the same condition in native kidney [3].

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