Thank you, Dr. frankbj for posting this interesting case.

The most impressive change is the hyalinizng arteriolosclerosis. Though it is not nodular, I still think it is part of CNI toxicity. The glomeruli appear unremarkable.

Focal C4d stain in peritubular capillaries could be the result of acute antibody mediated rejection. But this needs to correlate with donor specific antibody status.

There is mild tubulitis (t1). Given the extent of interstitial mononuclear infiltration, it is not enough to diagnose acute T-cell-mediated rejection.  The vacuolization of tubular epithelial cells is seen. But it is not that type which is seen in acute drug toxicity.

病理诊断：首先考虑高血压因素所致移植肾细小动脉和入球微动脉病变。同时，结合移植肾活检组织内部分PTC内皮和肾小球内毛细血管内皮呈C4d阳性沉积，请临床复查PRA或DSA滴度水平，以排除存在单纯抗体介导性排斥反应因素可能。经临床检测PRA为阴性，排除抗体介导性排斥可能。

临床：移植肾肾图检查为梗阻表现，输尿管轻度扩张积水，盆腔少许积液，经输尿管镜检查+双J管置入治疗，肾功能恢复好，肌酐降为正常水平。

请教

 谢谢给出最终诊断。