Late Renal Allograft Dysfunction

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Mixed Antibody-Mediated and Chronic Active T-Cell-Mediated Rejection • Case Summary

Clinical	30-year-old female; living-related renal transplant20/08/2017; -9 years post-transplant; worsening grak function.
Laboratory	Creatinine 3.96 mg/dL; BUN 83.8 mg/dL; urine protein 1+; blood 1+; albumin 2.8 g/dL; Hb 10g/dL.
Biopsy	7/7 glomeruli globally sclerosed; 25-50% IFTA; dense interstitial inflammation; significant tubulitis; prominent peritubular capillaritis.
C4d	3+ with linear staining in >50% peritubular capillaries. Supports complement activation and an antibody-associated process.
Interpretation	Antibody-mediated component plus chronic active T-cell-mediated rejection, Banff grade IВ, with substantial chronic allograft injury.
Treatment	IV methylprednisolone 500 mg OD for 3 days, followed by oral prednisolone. Creatinine improved to 1.5 mg/dL.

What must be correlated

DSA, tacrolimus/cyclosporine lsvsJs, immunosuppression adherence, BK-virus PCR, prior biopsy findings and the renal
function trajectory. C4d alone should not be treated as sufficient for definitive ABMR classification.

Prognostic point

The creatinine response suggestsa steroid-responsive active inflammatory component. However, 25-50% IFTA and global
sclerosis of all 7 sampled glomeruli represent established chronic injury, some of which is irreversible.

Presentation closing line

“This case demonstrates that late renal allograft dysfunction may reflect simultaneous active immune-mediated injury and
advanced chronic scarring; accurate classification requires integration of biopsy findings with C4d and DSA.”