What is your diagnosis in this transplant biopsy given the features present?
Answer: Chronic active antibody-mediated rejection
The features in the image are compatible with chronic active antibody-mediated rejection. The image depicts a glomerulus via the Jones silver stain and highlights two key features of rejection.
First, within the glomerular capillary loops we can appreciate circulating mononuclear cells with associated endothelial swelling and occlusion of the glomerular capillary loops, compatible with glomerulitis. Additionally, the silver stain helps us to also identify double contours, indicating chronic endothelial injury. Thus, the features indicate not only acute/active features of antibody-mediated rejection but also suggest that this process has been ongoing or possibly that this patient has had waxing/waning antibody-mediated rejection as chronic endothelial injury has also occurred leading to double contour formation (i.e. transplant glomerulopathy).
The biopsy also demonstrated severe peritubular capillaritis, diffuse C4d staining, and clinically was found to have high titer donor-specific antibodies.
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