case_images: PMC8017890_01
case_images: Light micrographs of kidney transplant biopsy. (A) Glomerulus with intracapillary fibrin, red cell fragments, and karryorhectic debris (hematoxylin and eosin x 40). (B) Segmentally sclerosed glomerulus with double contouring and fibrin (silver x 40). (C and D) Arterioles with fibrin, and focal onion skinning with myxoid intima, red cell fragments, and karyorrhexis (C: hematoxylin and eosin x 40; D: silver x 40).
case_images: JKCVHL-8-025-g001.jpg
case_images: PMC8017890_01_JKCVHL-8-025-g001.jpg
case_images: F1
case_images: Owing to lack of improvement in his kidney function, he had an allograft biopsy on the third day three of admission, which demonstrated glomerular and arteriolar changes of chronic active TMA (Figure 1).
case_images: Electron micrographs of kidney transplant biopsy. (A) Mesangial expansion by increased mesangiocytic processes and electron dense deposits. (B and C) Subendothelial lucent widening with loss of endothelial fenestrations, mesangial interpositioning, and intramembranous electron-dense deposits. (D) Higher power view of deposits showing vaguely fibrillary substructure.
case_images: JKCVHL-8-025-g002.jpg
case_images: PMC8017890_01_JKCVHL-8-025-g002.jpg
case_images: F2
case_images: Widespread mesangial, paramesangial, intramembranous, and subendothelial electron dense deposits with a vaguely fibrillary substructure were also noted (Figure 2).
case_images: Serum creatinine and trough ciclosporin levels compared against time from admission, and commencement of both pazopanib and cabozantinib.
case_images: JKCVHL-8-025-g003.jpg
case_images: PMC8017890_01_JKCVHL-8-025-g003.jpg
case_images: F3
case_images: Eculizumab was considered; however, as DITMA was more likely than atypical HUS, and because serum creatinine continued to downtrend (Figure 3), eculizumab was not pursued. TMA has also been reported in association with cabozantinib. Three months following discharge, serum creatinine dropped below 200 micromol/L; however, the patient continued to experience nephrotic range proteinuria (Figure 3).