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- Status post kidney transplant Day 1, delayed graft function.
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| 标本名称： | Transplant kidney, Day 1. | ||||
| 简要病史： | The patient received a kidney 20 hours ago. No urine is produced. Our clinician thought this was acute rejection.
The donor was an alcoholic.She was drunk and fell, then suffered cerebral hemorrhage and died. One of her kidneys was transplanted to the other recipient and functioned well! | ||||
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本帖最后由 于 2009-11-19 07:32:00 编辑
×参考诊断
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本帖最后由 于 2009-11-19 08:03:00 编辑
The above is the Day 1 biopsy. The following is the Day 7 biopsy. C4d stain is still negative.
I have no ready answer to this case. But I am almost one hundred percent sure that this is not acute rejection. My feeling is that this is some sort of cast nephropathy. On Day 7, the casts are degrading, losing eosinophilia on H&E stains, turning bluish on trichrome stains and attracting neutrophils into the tubular lumens. Dr. Geng had a similar case in a native kidney.
Is there anybody who has photos of hemoglobinuria related ATN?
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| 以下是引用geng72在2009-11-19 21:10:00的发言： 在我们的病例中有2例曾经看到这样的管型，还都是来自同一家医院，和临床联系时没有溶血、没有肌肉的挤压伤，没有肾功能的改变，最终的诊断只能是特殊蛋白管型，我自己认为还是血红蛋白管型，不过没有证实过。 |
I am still puzzled by the casts. 血红蛋白管型 is also my guess. But the hemoglobin A stain is not definitive. Here is a paper regarding transplant kidney with cast nephropathy (see below). however, my patient did not have rapamycin and tracrolimus.
Reference:
Delayed graft function and cast nephropathy associated with tacrolimus plus rapamycin use. Smith KD, Wrenshall LE,
| 以下是引用wfbjwt在2009-11-19 21:19:00的发言： 我感觉还是急性排斥反应，7天后的图片可以看到淋巴细胞浸润了，血管明显闭塞。估计第一天时主要是体液免疫，形态学难以识别。没见过，根据所学理论瞎猜的，请指正。血管中物质会不是跟输血或输液有关？ |
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本帖最后由 于 2009-11-27 05:36:00 编辑
In my report of the second biopsy, I stated that "cellular reaction to casts, predominantly by infiltrating neutrophils and rare macrophages, aiding resolution of the cast nephropathy. These morphological changes are also strikingly similar to these of myeloma cast nephropathy." Then our nephrologist ordered tests for serum and urine. The tests show this patient has large amount of free lambda light chain (Bence Jones protein) in urine and monoclonal IgG (lambda type) in serum . After we know all the results, the diagnosis becomes an easy one (light chain associated cast nephropathy).
