Thank you, frankbj for posting such an interesting and challenging case.  The arteriolar changes are most eye-catching. From the previous case you posted, I learned that the bright red stain in the vascular wall represent hyalinosis. The location of some hyalinosis is the abluminal aspect, and some of them appear slightly nodular. These changes may indicate chronic CNI toxicity.

In addition, there is background mononuclear infiltrate. Its significance will depend on the extent or percentage of the involvement.

There is probable glomerulitis. But its significance is controversial in cellular rejection. Occasional probable double contour is seen. Do you do routine silver stains? If it is confirmed by silver stain or EM (I routinely do EM on transplant kidney), chronic transplant glomerulopathy will be the second diangosis in the report.

The tubular changes are subtle. The dilatation may indicate acute injury. Please let us know your thought.

 

          其中多个肾小球入球动脉可见明显的透明样变，肾小球局部系膜基质轻度增生，局部毛细血管基底膜轻微增厚。细小动脉分支未见异常。肾组织间质内未见淋巴细胞浸润，未见肾小管上皮炎及血管内皮炎等排斥反应表现。肾组织间质局部基质轻微增生，极少数肾小管轻度萎缩，余绝大多数肾小管未见明显异常。综上所见结合术后血药浓度变化，在排除明显高血压前提因素下，初步考虑为免疫抑制剂所致的轻度的慢性毒性损伤。

 Thank you, frankbj.

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