移植肾活检组织可见18只肾小球和6支细小动脉分支， 其中，5只肾小球硬化废弃，大部分肾小球可见局灶性系膜基质增生，部分呈分叶状改变；细小动脉分支内膜基本正常，

Thank you, frankbj for sharing this interesting case with us.

I agree with frankbj's assessment that 细小动脉分支内膜基本正常. It seems that the glomeruli demonstrate some features of chronic transplant glomerulopathy.  EM is probably the most reliable tool to detect early changes of chronic transplant glomerulopathy.

Photo #6 & #8 show proliferation of epithelial cells. If they are parietal epithelial cells, these cells represent partial crescent, which may be occasionally seen in chronic transplant glomerulopathy. But there should not be too many.

Photo #3-5 demonstrate isometric vacuolization of tubular epithelial cells. This change is often interpreted as acute drug toxicity. However, in heavy proteinuria and lipiduria patients, some tubules may have the similar appearance.

I don't routinely phenotype the infiltrating mononuclear cells.  I heard from some pathologists in a meeting that it is helpful in separating rejection from BK virus nephritis. I have no experience in interpreting the profiling.