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== Clinical Summary ==
This 39-year-old male had malignant hypertension with malignant nephrosclerosis, progressing to chronic renal failure. He underwent a bilateral nephrectomy for control of his hypertension and received a cadaveric renal transplant. He did well, although he developed diabetes mellitus and had persistent, but less severe controllable hypertension. Two years following transplantation he was admitted to the hospital for control of his hypertension and evaluation of his chronic rejection. Initial blood pressure while in the hospital was in the range of 160/110 to 160/100 mm Hg. He was placed on a more intensive hypertension regimen, and he gradually became normotensive. He received one hemodialysis treatment prior to discharge. At the time of discharge, his blood pressure was 100 to 110 over 60 to 70 and he was doing well on dialysis. His BUN was 113 mg/dL and creatinine 5.2 mg/dL, and he had a hematocrit (PCV) of 27%. The patient was again admitted one month later for evaluation of azotemia and for control of his hypertension. It was felt that his chronic rejection was end-stage and that he would have to be dialyzed periodically. He was put on a renal failure diet, and over the period of his hospitalization, his BUN and creatinine finally stabilized at high levels. He tolerated dialysis well, and a transplant nephrectomy was done at 2 1/2 years post transplant. At the time of discharge, the patient's BUN was 78 mg/dL, creatinine 3.6 mg/dL, WBC 5000 cells/mm³, and the PCV was 26%.
== Surgical Pathology Findings ==
The kidney weighed 215 grams and was covered by a thick capsule, which was partially adherent to the cortex, but could be stripped from the kidney with slight difficulty. The calyces and pelvis of the kidney appeared normal. The vessels were not prominent. The renal arteries and vein appeared normal.
== Images ==
<gallery height="250px" widths="250px">
File:IPLab6ChronicRejection12.jpg|Photomicrograph from another region of previous image. Note the cellular infiltrate around a small blood vessel (right) and neutrophils within renal tubules (arrow).
</gallery>
== Virtual Microscopy ==
<peir-vm>IPLab6ChronicRejection</peir-vm>
== Study Questions ==
* <spoiler text="What is the pathogenetic mechanism of chronic transplant rejection?">Basically, chronic transplant rejection is the accumulated damage to the kidney that results from multiple episodes of acute transplant rejection. Despite immunosuppressive therapy, there is still some ongoing rejection and there are often flare-ups of acute rejection. Over time this cumulative damage results in loss of renal tissue and replacement by fibrous connective tissue.</spoiler>
* <spoiler text="Why does this case of chronic transplant rejection have cellular infiltrate and even some neutrophils (indicating acute inflammation)?">There is often ongoing rejection even in cases of long term transplant. This case and the images from the case of chronic rejection that was removed during an attack of acute rejection demonstrate the continuing ongoing nature of the rejection process.</spoiler>
* <spoiler text="What role do humoral antibodies play in chronic transplant rejection?">There is some controversy over this point. Some people think that since antibodies can be demonstrated in the vascular lesions (the intimal proliferation), these must be antibody-mediated. This is not necessarily true but the classic dogma is that chronic vascular rejection is both antibody-mediated and cell-mediated.</spoiler>
== Additional Resources ==
=== Reference ===
* [http://emedicine.medscape.com/article/429314-overview eMedicine Medical Library: Assessment and Management of the Renal Transplant Patient]
* [http://emedicine.medscape.com/article/430128-overview eMedicine Medical Library: Renal Transplantation]
* [http://emedicine.medscape.com/article/241640-overview eMedicine Medical Library: Malignant Hypertension]
* [http://www.merckmanuals.com/professional/cardiovascular_disorders/hypertension/hypertensive_emergencies.html Merck Manual: Hypertensive Emergencies]
* [http://www.merckmanuals.com/professional/genitourinary_disorders/renal_failure/chronic_kidney_disease.html Merck Manual: Chronic Kidney Disease]
* [http://www.merckmanuals.com/professional/genitourinary_disorders/renal_replacement_therapy/hemodialysis.html Merck Manual: Hemodialysis]
* [http://www.merckmanuals.com/professional/immunology_allergic_disorders/transplantation/kidney_transplantation.html Merck Manual: Kidney Transplantation]
=== Journal Articles ===
* Matas AJ. [http://www.ncbi.nlm.nih.gov/pubmed/11272615 Impact of acute rejection on development of chronic rejection in pediatric renal transplant recipients]. ''Pediatr Transplant'' 2000 May;4(2):92-9.
=== Images ===
* [{{SERVER}}/library/index.php?/tags/2146-rejection PEIR Digital Library: Rejection Images]
* [http://library.med.utah.edu/WebPath/IMMHTML/IMMIDX.html#4 WebPath: Transplant Rejection]
== Related IPLab Cases ==
* [[IPLab:Lab 1:Kidney Infarction|Lab 1: Kidney: Infarction (Coagulative Necrosis)]]
* [[IPLab:Lab 6:Acute Rejection|Lab 6: Kidney: Acute Transplant Rejection]]
* [[IPLab:Lab 10:Candidiasis|Lab 10: Kidney: Candidiasis]]
{{IPLab 6}}
[[Category: IPLab:Lab 6]]