Acute Rejection Classification

1
Acute Rejection Classification

• Cell-mediated rejection Types 1,2,3
  (tubulointerstitial, vascular, transmural) as
  before
• Antibody-mediated rejection (suspicious if C4d
  or antibody negative) 1 ATN-like changes with
  C4d and circ. anti HLA antibody 2
  Capillary- glomerulitis, polys and monos in PTC
  with circ. anti HLA antibody /or C4d. 3
  Arterial - transmural inflammation/fibrinoid
  change with circ. anti HLA antibody /or C4d.

2
V3 in Cell Mediated Rejection

• Kim Solez, M.D. and
• Alexei Sukhanov, M.D

3
V3 in Cell Mediated Rejection

• V3 common in transplant nephrectomies
• Following withdrawal of immunosuppression.
• Often C4d not done.
• Some cases almost certainly represent severe cell
  mediated rejection.
• Is V3 found in severe cell mediated rejection on
  biopsy?

4
Two Cases of V3 on biopsy in Cases of Cell
mediated rejection since 1997

• Both had features of cell mediated rejection
• C4d Negative
• Tubulitis.
• Clinical history not suggestive of antibody.

5
Two Biopsy Cases - Negative for C4d

• M.T. Tx - 18 March 1997
• Bx 1. 18 March 1997 (baseline Bx) - No
  diagnostic changes (G0 I0 T0 V0 AH1)
• Bx 2. 25 March 1997 . History -? Rejection
  Dx possible CsA tox with endothelial injury
  superimposed on acute interstitial rejection.
• Bx 3. 03 April 1997 . History Recent creat
  rise, Acute rejection? Dx Severe "vascular"
  rejection with minimal tubulointerstitial
  component. (G0 I2 T1 V3 AH0)

6
Two Biopsy Cases - Negative for C4d

• JV Tx -18 August 1999
• Bx 1. 18 August 1999(baseline) - Mild
  degenerative tubular changes withhyaline
  arteriolar thickening. (G0 I0 T0 V0 AH1)
• Bx2 2. 12 November 1999 . Base creat. 140, but
  now unstable over 200. Dx Acute vascular
  rejection with probable viral infection(?BK-virus)
  , (G0 I3 T3 V1 AH0)
• 3. 03 December 1999 Rebiopsy as creat starting
  to change. DxSevere acute rejection (category 3)
  Banff score G0 I2 T2 V3 CG0 Ci1 CT1 CV1 AH0

7
Two Biopsy Cases - Negative for C4d

• JV Tx -18 August 1999
• Bx 1. 18 August 1999(baseline) - Mild
  degenerative tubular changes withhyaline
  arteriolar thickening. (G0 I0 T0 V0 AH1)
• Bx2 2. 12 November 1999 . Base creat. 140, but
  now unstable over 200. Dx Acute vascular
  rejection with probable viral infection(?BK-virus)
  , (G0 I3 T3 V1 AH0)
• 3. 03 December 1999 Rebiopsy as creat starting
  to change. DxSevere acute rejection (category 3)
  Banff score G0 I2 T2 V3 CG0 Ci1 CT1 CV1 AH0

8
Conclusions

• V3 does occur in cell mediated rejection
• Classification has to accept occurrence of V3 in
  both cell mediated and antibody mediated
  rejection.