Background: Renal transplantation is the preferred form of treatment in patients with end-stage renal disease. Despite potent immunosuppression, the patient can develop graft failure in early and late posttransplant period due to immune and nonimmune causes. Graft nephrectomy is uncommon procedure and is being performed for graft failure due to vascular thrombosis, hyperacute rejection, and acute rejection nonresponsive to immunosuppressive treatment in early graft failures and primarily due to graft intolerance in later graft failures. Studies on graft nephrectomy are limited with even fewer studies detailing the histopathology of graft nephrectomy exist in the present literature. The present study describes the detailed histopathology of both early and late graft nephrectomy specimen from a large transplant center in India along with their clinical profile and indications. Materials and Methods: Ten-year retrospective analysis of graft nephrectomy cases was performed from January 2014 up to December 2023. Clinical presentation, immunological profile, and biochemical parameters were obtained from the hospital records. Follow-up was recorded from the medical records. Histopathology changes in the graft nephrectomy specimen were retrospectively analyzed in detail by an experienced renal pathologist and were evaluated in detail along with C4d immunohistochemistry in both early and late graft nephrectomy specimen. Results: Majority of the patients in our cohort underwent early graft nephrectomy. Eleven cases of early graft nephrectomy were ABO incompatible as compared to just one patient with late allograft nephrectomy and the association was significant, P = 0.018. There was a significant association between acute antibody-mediated rejection and subsequent early graft nephrectomy ( P = 0.008). The most common indication in cases of early graft nephrectomy was vascular thrombosis and histopathology showed extensive renal parenchymal necrosis with renal artery or vein thrombosis. In late graft nephrectomy group, graft intolerance formed the most common indication. Histopathology showed the features of mixed chronic and acute rejection. Interstitial fibrosis/tubular atrophy and arterial fibrous intimal thickening were common in late graft nephrectomy. Malignancy and infection were the rare diagnosis on histopathology of graft nephrectomy. Conclusion: This study provides a detailed description of the histopathology of early and late graft nephrectomy specimens along with their clinical profile with indications. Histopathology findings although correspond with clinical findings in the majority but may be beneficial in understanding the underlying immune mechanisms in patients experiencing graft intolerance syndrome and managing the transplant recipients in the event of unexpected diagnosis like fungal infection and malignancy.
Gupta et al. (Thu,) studied this question.