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nbme22/Block 3/Question#47 (41.2 difficulty score)
A 10-year-old boy receives a renal transplant ...
Lymphocytes infiltrating tubular epitheliumπŸ”,πŸ“Ί
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 +4 
submitted by nwinkelmann(297),
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turpyHcaee = isuenmt to uoh,rs thso feomerpdr bA sganati ftrga atdhlleioen clel gA = cmnmptileo vino,tcatai tneeidohlal ad,geam fatimmanlion nii(thw eth s,uiest NTO te,iint)miutsr titnlgoc cead,acs ccisehim nsrioces dna msohisbot.r :hcsp/mrunj.ta.py/hiroluticltpK.k/sAH/mysdpbteRcieimt/

uAcet = wekse to nthosm = tfarg Ag aictstvea thos CD4 dan DC8 T lsecl enailgd to nyapcahemlr lcel amd,gea siirtlnttiae cohcypmytil it,ntlinaofri dna tiisnilt.oheade dth//cljm/ktpaioMt.AibRscre.m:yn.Kt/u/slphtpmseydriopi

Chrocni = hnmost to yse,ra ioncrhc DHT tpey( IV yvyiensttri)eishp ioatcern ni seelvs lwla enaldgi ot itliamn motohs mlecus lcel aprtilofonrei dan esvels ,soiclunoc ihwt syopbi sinhgow roawerdn usavlacr meuln nda eetnevsxi tosomh msc.uel

HDGV = afgrt ecsll smot( illpatycy enob rwrmao sptrnsl)tnaa iznergceo ohst eclsl as gsff/nlreoie dan elad ot iucsrdnteto fo hsto usseit enaldgi to ha,rs cdu,aejin ed,arihra and IG mgrerhehao s(hti srocuc uecbaes omts nbeo rwmrao plaattnnsr tisepant ehva ngeeunrdo flul aotriiand cwhhi ttskcaa hte yiplrad iodvprngi lclse smto (i..e nksi, IG csom,au rha,i aysoehtec)tp so agtfr deniuttsocr of thso sllce ni etsho rasea adsle ot .mptoms)sy

.uti/htmpocs/mc/s:pp.t




 +2 
submitted by niboonsh(360),
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hiTs si a aces fo aeutc tapntnrsal ieoejtrn.c eksew to tonhsm feart eth asn,rptnatl etierinpc d8c n/odra cd4 t cslle era tcadvatei ngsitaa the noord a( ypet 4 SRH) dna teh nodro ttssra mikagn steoiabndi agnitsa the altnprtasn. sThi tssnepre sa a csvlausiti thwi ensde riieilsattnt imyyhcotplc sal.itrefnti (A80F21 gp )119

ls3076  Actually was confused about this due to a UW explanation. UW said acute txp rejection has two types - humoral and humoral and cellular. Humoral has Neutrophilic infiltrate + necrotizing vasculitis while cellular has lymphocytosis. Can anyone simplify/explain this please? +3  
apurva  We usually look for c4d complement for humoral response in acute graft rejection. Because c4d makes covalent bond with the endothelium can can be found on staining because it is long lasting. +  



 +2 
submitted by adisdiadochokinetic(77),
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aCn ennyao eplinax yhw iForbus sscar ihtw lpasam elslc si not teh teocrrc n?sewar

osler_weber_rendu  Exactly. Three months can fall under chronic rejection as well. FA pg 119 states "interstitial fibrosis". Chronic rejection is predominantly Bcell mediated (plasma cells). +  
beto  chornic rejection > 6 month acute < 6 month +3  
beto  also there are no B cells in the site of fibrosis. humoral response due to antibody themself,not by direct B cells response +2  



 +0 
submitted by mcl(601),
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gepa 119 i naPeFtAt is tespiegnnr tomnhs frtea eth altnprtn,sa wchih samen ti c'nat be yrceeahupt unelss he seoptdp natgki sih enspitmu.rpnuasssmo u//hccAoHtnrVeciG edsseai rea eimadedt yb T sllce rof hte sotm tpar I( ,ti)knh os tihs olwud amen iotyyhcplmc fler.staniti

usmleuser007  It is very unlikely to be GVH disease b/c it's more common if the host is suppressed as in if host had ablated bone marrow. (FA states that it's more common with bone marrow & liver transplants) +3  
usmleuser007  any one care to explain why fibrous scars with plasma cells not a good option?... +2  



 +0 
submitted by snoochi95(2),

Does anyone know why this is not Chronic rejection? They both fit within the time frame.




 +0 
submitted by lowyield(26),

I think the three most reasonable answers can be put into the different boxes of rejection

Glomerular neutrophils and necrosis->hyperacute (? I usually just think neutrophils are the earlier onset things)

Lymphocytes infiltrating tubular epithelium-> Acute [<6 mo]

Fibrous scars and plasma cells ->these two key words seem more like chronic etiologies (this extends beyond graft rejection)

My best guess at the other options are:

Arteriolar C3 deposition- some sort of nephritic syndrome, whether it's SLE, PSGN etc.

Dilation of Bowman's space-post-renal obstruction

RBC casts- nephritic something something, basically it's glomerular rather than interstitial bleeding

Subcortical necrosis- diffuse cortical necrosis caused by obstetric catastrophes/septic shock/DIC etc.