CLINICAL PRESENTATION

A 73-year-old man, with end-stage renal failure secondary to ADPKD was transplanted with a deceased allograft kidney in 1996. Between 1996 and 2004, he was immunosup-pressed with cyclosporine, azathioprine (AZA) and prednisone (PDN). In 2004, after the diagnosis of squamous-cell carcinoma of the lip, the immunosup-pression was changed to sirolimus (SRL) and AZA. Since 2010, after sepsis with pulmonary origin, he was in monotherapy with SRL. Along these years, the serum creatinine increased slightly from 1.2 to 1.8 mg/dl. A diagnosis of adenocarcinoma in the right upper pulmonary lobe was made, in September 2013, and the patient underwent a right upper lobectomy in November 2013. The serum creatinine was 1.9 mg/ dl at discharge after surgery. At this time, the siro-limus was switch to tacrolimus. An allograft kidney biopsy was done 75 days after surgery, due to creatinine increase (1.9 to 3.2 mg/ dl), with a proteinuria of 50 mg/dl. The following figures demonstrate the main morphological aspects of the biopsy. HISTOLOGICAL DIAGNOSIS The paraffin-embedded fragment shows kidney cortical with a total of six glomeruli and several medium-sized arteries. The frozen fragment shows four glomeruli and the search of C4d in peritubular capillaries by immunofluorescence is negative. Acute allograft kidney dysfunction 18 years after transplantatio