PMC3505949_01
Computed tomography scan showing hyperdense areas in the renal allograft, in keeping with foci of parenchymal haemorrhage.
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fig1
An enhanced abdominal computed tomography (CT) scan revealed few scattered hyperdense foci in the renal allograft, in keeping with microhaemorrhage and microperforations (Figure 1).
Oblique laceration on in the upper pole and mid portion of the kidney compatible with ruptured graft.
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fig2
An oblique laceration that measured 4 cm in length and involved the upper pole and the mid portion of the graft was evident (Figure 2).
Marked interstitial oedema and haemorrhage (H&E x100).
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fig3
T-cell mediated (cellular) rejection, in a background of marked chronic allograft arteriopathy. The interstitium was markedly oedematous and showed areas of extensive haemorrhage (Figure 3).
Severe endarteritis was readily identified in the interstitial blood vessels (PAS stain x200), along with arterial and arteriolar fibrinoid necrosis (Inset H&E x200).
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fig4
This was associated with severe lymphocytic tubulitis, acute tubular epithelial cell degenerative and regenerative changes in the viable renal tubules, and severe endarteritis with fibrinoid necrosis (Figure 4).
Fibrin microthrombi were also seen in the glomeruli (PAS x200). Glomerulitis in the form of mononuclear inflammatory cells infiltrating the glomerular capillaries was seen (Inset PAS x200).
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fig5
Mild glomerulitis, congestion, and fibrin microthrombi were identified in the viable glomeruli (Figure 5).
The morphological features of the acute rejection were found in a background of severe chronic allograft arteriopathy (H&E x40, inset PAS x200).
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fig6
Marked chronic allograft vasculopathic changes in the form of severe fibrointimal thickening and presence of intimal and subintimal foamy aggregates were readily seen in the interstitial blood vessels (Figure 6).
Immunohistochemical staining for C4d shows diffuse linear and strong circumferential staining in the peritubular capillaries, consistent with acute antibody-mediated rejection (C4d IHC x100).
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fig7
Immunohistochemical staining for C4d (dilution 1 : 40, polyclonal Abcam, Cambridge, UK) showed diffuse linear staining in peritubular capillaries in the renal cortex and medulla, indicating a concurrent active antibody-mediated rejection (Figure 7).