Looks Can Be Deceptive Case presentation 37 y/o man Original - - PowerPoint PPT Presentation

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Mar 14, 2023 153 likes •330 views

Looks Can Be Deceptive Case presentation 37 y/o man Original kidney disease: Polycystic kidney disease, HTN, highly sensitized Live unrelated renal transplant Jan.2018 5 months post transplant: rising serum Cr.

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“Looks Can Be Deceptive”

Case presentation

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37 y/o man
Original kidney disease: Polycystic kidney disease,
HTN, highly sensitized
Live unrelated renal transplant Jan.2018
5 months post transplant: rising serum Cr. (94—180)
No proteinuria
Urine and serum viral load: Negative (1 month prior to biopsy)
U/S – No obstruction, perfused kidney
Medications: Steroids, Myfortic & prograft : full maintenance

doses

? Acute rejection

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Pathologic Finings Summary

(30 glomeruli & 1 artery) Glomeruli‐ 0/30 GS, g0, cg0 Tubulointerstitum‐

t1 + i1
ATI
No significant IF/TA(ci0,ct0)
No definitive viral cytopathic change

Vessels‐ v0 , cv0

ptc 0
C4d negative

Differential diagnosis ?

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SV40 SV40

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p53 p53

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Diagnosis

Polyomavirus associated nephropathy (BK virus nephropathy)

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Post‐biopsy management

Full response

Downgrade immunosuppresion + IVIG

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Measurement of decoy cells in urinary sediments may predict early

BKV infection

Useful for screening and continuous monitoring.
Frequent urinary BK viral load screening for the prevention of BKVN

due to its high sensitivity and earlier detection

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PVAN and acute rejection are not easy to distinguish without arteritis/ glomerulitis
HLA‐DR, lymphocytic infiltrate, tubulitis in areas lacking BKV suggest concurrent ACR

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p53 staining:

detects a higher percentage of BK virus infected cells than SV40 staining alone.
sensitive and specific method when used along with SV40 staining.

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Take home message

Morphologic overlap between TCMR and PVAN
High index of suspicion & SV40 can be helpful in borderline

changes

Early PVAN may lack viral cytopathic changes

Questions to consider: ‐ Routine SV40 ? ‐ Management of grafts with acute TCMR and positive SV40? ‐ Urine cytology vs. urine PCR to monitor BKV reactivation Questions to consider: ‐ Routine SV40 ? ‐ Management of grafts with acute TCMR and positive SV40? ‐ Urine cytology vs. urine PCR to monitor BKV reactivation

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