Untitled - Roche Trasplantes

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PROTOCOL BIOPSIES AND THE DIAGNOSIS OF HUMORAL REJECTION Figure 4. Chronic transplant glomerulopathy with thickening and duplication of peripheral basement membranes. In capillary loops still inflammatory cells can be appreciated as a sign of ongoing immunological damage to the endothelial cells. Yet (2006), specific pathological features of chronic humoral rejection are not officially part of the current up-dated Banff classification system. However, at the two recent Banff meetings in 2003 and 2005 an open-forum consensus-discussion was proceeded to confirm the entity of chronic humoral rejection and to define diagnostic criteria. In was agreed that this entity exists and that it should be part of the classification in the future. Based on several publications, beside non-specific features of chronic allograft damage like tubular atrophy and interstitial fibrosis, the following pathological features appear to be specific diagnostic hallmarks of chronic antibody-mediated allograft damage: • Duplication of glomerular basement membrane, i.e., chronic allograft glomerulopathy (Figure 4, Figure 5). • Intimal myofibroblastic and foam cell proliferation in allograft arteries (Figure 6) with infiltration of mononuclear cells and few T-lymphocytes (Figure 7), i.e., chronic allograft vasculopathy. 57
BIOPSIA DE PROTOCOLO EN EL TRASPLANTE RENAL Figure 5. Electron microscopy of a glomerulum showing duplication of the basement membrane as the morphological hallmark of chronic transplant glomerulopathy. Typically no diffuse foot process effacement is seen, electron dense deposits might be present in the expanded subendothelial space. • Lamination of peritubular capillary basement membrane, i.e., chronic allograft capillaropathy (Figure 8). At 1 year after transplantation around 30% of renal allografts show signs of chronic humoral rejection, i.e., one or more of the above mentioned morphological features plus C4d deposition in peritubular capillaries. In parallel to acute humoral rejection again both, C4d and pathology have to be present to make the diagnosis of chronic humoral rejection from an allograft biopsy. Frequently additionally to signs of chronic antibody mediated allograft damage morphological features of acute humoral activity (capillaritis, glomerulitis) can be observed indicating an acute flare or ongoing antibody 58
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