Case :

Dr Milap Shah
 Clinical History
• 42 year old male underwent lung transplantation on for end stage
lung disease in case of Bilateral Bronchiectasis.
• Native lung explant specimen shows biateral lung showing
bronchiectasis with changes related to end stage lung disease.
• Pre transplant work up
• No prior history of Blood transfusion.
• Autoimmune profile by IF and ELISA: Negative
• No past history of tuberculosis or any fungal infection.
• No past history
DSA
FLOWCYTOMETRY CROSSMATCHING
Histopath of lung explant
• On day 1 post transplant
• On day 2 biopsy transbronchial lung biopsy from performed on Right
middle and lower lobe.
M
M
• In view of biopsy findings of DAH with capillaritis, testiing for Donor
specific antibodies (DSA) and Single antigen bead test were carried
out along with High resolution typing of Donor for virtual cross match.
DSA
SAB
Other work up

• HSV 1 and 2 Qualitative PCR: Negative

• Blood cultures: Negative
• CMV Quantitative PCR: Not detected
• BAL Fluid Fungal PCR: Not detected
On Radiology, Day 2 post transplant X ray
Diagnosis and intervention
• Antibody mediated Rejection in a appropiate clinical context.
• PLEX, IV IgG and Pulse steroid were initiated on Day 2.
On Day 6 post transplant Xray
On Day 10 CT scan and angiograpghy
Outcome
• Patient expired on day
AMR in Lung
• Multidimensional approaches for AMR diagnosis,including classification,
histological and immunohistochemical analysis, and donor‐ specific
antibody (DSA) characterization with their current strengths and
limitations were reviewed in The Lung session of the 2017 14th Banff
Foundation for Allograft Pathology Conference, Barcelona .

• The arbitrary nature of temporal divisions of AMR into hyperacute

(occurring intraoperatively or within 24 hours of surgery), acute (often
mimicking ACR) and chronic (potentially manifesting as an occult cause
of CLAD).
Criteria to define acute pulmonary AMR: allograft dysfunction, DSA positivity,
histopathology consistent with AMR, tissue C4d staining, and the exclusion of
other causes of allograft dysfunction.

“Definite AMR” has all criteria present and other possible causes excluded, noting that ACR and AMR may
coexist. “Probable AMR” lacks 1 criterion or other possible causes have not been excluded, whereas
“possible AMR” has 2 criteria missing.
Sub-clinical AMR: Histologic criteria of AMR detected on
surveillance transbronchial biopsies (with or without C4d and with or
without the presence of DSA) in the absence of allograft dysfunction.
• Neutrophilic margination is characterized by increased numbers of
neutrophils within septal capillaries but lacking capillary injury, in
particular, the absence of karyorrhexis.
• Neutrophilic capillaritis is defined as patchy or diffuse septal capillary
neutrophilic collections associated with cellular karyorrhectic debris.
• Other features can include microvascular thrombi, alveolar
hemorrhage, and/or accumulations of neutrophilic infiltrates within
adjacent alveolar airspaces.
• To date, these findings have been evocative but rather insensitive
markers of AMR.
• Other patterns reported in AMR include persistent or recurrent high‐
grade ACR, LB, and OB.
C4d staining
• 3‐category classification with 2 cut‐offs (negative if <10%, weak if
between 10% and 50%, and positive if >50%).
• Poor correlation, false positivity in infection and reperfusion and C4d
negative AMR.
DONOR‐SPECIFIC ANTIBODY (DSA)
Treatment Efficiancy