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Chronic CNI Nephrotoxicity — ESENeph MCQ

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ModerateTransplantationChronic CNI NephrotoxicityESENeph

A 48-year-old kidney transplant recipient 18 months post-transplant has slowly rising creatinine (from 115 to 160 umol/L over 6 months). Tacrolimus trough is 6.2 ng/mL. There are no DSA detected. Biopsy shows interstitial fibrosis and tubular atrophy (IFTA grade II) with arteriolar hyalinosis. C4d is negative. What is the diagnosis?

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Correct answer: E — Chronic calcineurin inhibitor nephrotoxicity

IFTA with arteriolar hyalinosis (nodular/circular hyaline deposits) in the absence of DSA and C4d is the characteristic histological pattern of chronic CNI (Tacrolimus) nephrotoxicity. This is one of the most important causes of chronic allograft dysfunction. Management involves minimising CNI exposure (dose reduction or conversion to CNI-free regimen with mTOR inhibitor or Belatacept), optimising BP, and adding RASi for proteinuria.

Reference: Banff 2019 Classification; KDIGO 2009 – Transplant Guideline