Fig. 1, 4, 5 and 9 show microthrombi in glomerular capillaries. Given the positive C4d stain, acute antibody-mediated rejection is suggested.  Drug induced HUS is the differential diagnosis. But the C4d result and patchy tubular necrosis in Fig. 5 favor acute antibody-mediated rejection. The arteries demonstrate intimal edematous change. My experience tells me that the edematous change is non-specific.

 

肾移植术后血栓性微血管病（Thrombotic microangiopathy after kidney transplantation）。结合免疫组化C4阳性，符合为急性抗体介导的移植排斥反应。

参考文献：

The glomeruli show thrombosis or neutrophils or mononuclear leukocytes in capillary lumens. The tubulointerstitial compartment shows edema, hemorrhage, necrosis, mild inflammation, and neutrophils or mononuclear leukocytes in the peritubular capillary lumens. The blood vessels show thrombosis, thrombotic microangiopathy, fibrinoid necrosis, or transmural vasculitis. Strong staining for C4d in the peritubular capillaries is characteristic. A definitive diagnosis of AMR requires (1) morphologic evidence of acute tissue injury, (2) immunopathologic evidence for antibody action, and (3) serologic evidence of circulating donor-specific antibodies. Acute antibody-mediated rejection should be suspected if some but not all 3 criteria are met. -Arch Pathol Lab Med. 2007 Aug;131(8):1200-8.

Thrombotic microangiopathy (TMA) is a severe complication of kidney transplantation that often causes graft failure. TMA may occur de novo, often triggered by immunosuppressive drugs and acute antibody-mediated rejection, or recur in patients with previous history of hemolytic uremic syndrome (HUS). Recurrent TMA is very rare in patients who had developed end-stage renal failure following HUS caused by Shiga-toxin producing E. scherichia coli, whereas disease recurrence is common in patients with atypical HUS (aHUS). -Am J Transplant. 2010 Jul;10(7):1517-23.
In the literature, the most-frequent cause of hemolytic uremic syndrome in patients following renal transplantation is recurrence of the hemolytic uremic syndrome. Other causes include drug-related (cyclosporine, tacrolimus) toxicity, procoagulant status, and antibody-mediated rejection. We found that the most-frequent cause of thrombotic microangiopathy was drug related, secondary mainly to cyclosporine. -Exp Clin Transplant. 2004 Dec;2(2):268-72.