WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:14.020 --> 00:16.280 A United States Army Medical Department, 00:16.290 --> 00:18.309 continuing Education program, 00:19.299 --> 00:21.639 morphology of recurrent disease and 00:21.649 --> 00:22.770 transplantation 00:24.760 --> 00:27.750 with James D Mullin's major US Air Force Medical 00:27.760 --> 00:28.110 Corps, 00:28.440 --> 00:29.309 Wilford Hall, 00:29.319 --> 00:30.819 US Air Force Medical Center, 00:30.829 --> 00:32.330 Lackland Air Force Base. 00:33.840 --> 00:34.720 Just real quick. 00:34.729 --> 00:35.909 I'd like to go back through again. 00:35.919 --> 00:38.849 What he's talking about when you get some pathological change and more 00:38.860 --> 00:41.619 likely to change in the of a graph or several things you do have to 00:41.630 --> 00:42.310 consider. 00:42.439 --> 00:44.880 Number one is transmission arts, 00:45.189 --> 00:48.119 the existence of transmission I don't think can really 00:48.130 --> 00:50.930 be argued if you go back and look at the experience of Peter 00:51.389 --> 00:54.310 when they transplant the ISS identical twins, 00:54.330 --> 00:57.090 which there really should be no reason for uh any 00:57.099 --> 00:59.080 type of his incompatibility. 00:59.319 --> 01:02.159 17 of the 22 patients in an iso study 01:02.169 --> 01:03.979 had the I 01:05.430 --> 01:07.190 when they reviewed the his in the history, 01:07.330 --> 01:09.849 it felt that 17 to 22 had courses 01:10.069 --> 01:12.529 consistent with native arthritis. 01:12.540 --> 01:15.160 All for E M work really wasn't done. 01:15.489 --> 01:17.739 I got 17 which was felt to have native 01:18.550 --> 01:20.389 uh or native kidney. 01:20.400 --> 01:23.089 11 reoccurred with morphological changes of 01:23.559 --> 01:25.080 arthritis and all that 11, 01:25.089 --> 01:27.699 either six or seven went on to lose their graft, 01:27.709 --> 01:30.309 all their life because of the to arthritis. 01:30.550 --> 01:32.139 So transplant, 01:32.150 --> 01:35.040 I mean transmission does exist at least in 01:35.050 --> 01:37.680 the has been well described and the 01:37.690 --> 01:40.610 autograph becomes much harder problem because here you run into the 01:40.620 --> 01:40.980 problem, 01:40.989 --> 01:43.330 the changes you see in the autograph immunity, 01:43.339 --> 01:45.199 the rejection process itself. 01:45.360 --> 01:47.860 Plus there's another very important difference between this is 01:48.260 --> 01:49.830 series and the autograph series. 01:50.050 --> 01:51.260 I mean nobody in this country, 01:51.269 --> 01:52.510 I am in Europe. 01:52.519 --> 01:54.900 Sometimes they will give autographs withhold imm 01:55.010 --> 01:57.769 suppression and H L A identical grasp in this country. 01:57.779 --> 02:00.059 Everybody with an autograph gets immuno suppression. 02:00.379 --> 02:02.870 And that obviously is gonna have some influence on the 02:02.879 --> 02:05.639 morphological and clinical expression of the transmission of 02:05.940 --> 02:06.449 arthritis. 02:06.739 --> 02:08.029 That is group. 02:08.039 --> 02:10.940 Only three of those people were treated prophylactically with uh 02:10.970 --> 02:13.009 immunosuppression for at least for the clinicians, 02:13.020 --> 02:14.000 maybe make you feel happier. 02:14.009 --> 02:16.190 It seems like at least if you start these people on 02:16.199 --> 02:17.119 immunosuppression, 02:17.130 --> 02:17.350 right. 02:17.360 --> 02:18.270 As soon as they get the kidney, 02:18.279 --> 02:20.850 you appear to uh at least delay or 02:20.860 --> 02:23.800 modify the transmission of arthritis from what we can 02:23.809 --> 02:24.320 tell. 02:24.369 --> 02:26.979 And most people that lose their kidneys and our experience and I think 02:26.990 --> 02:29.699 everybody else's experience lose their kidney through the 02:29.710 --> 02:30.899 process of rejection. 02:30.910 --> 02:33.380 Whether or not to have some degree of recurrence of 02:33.809 --> 02:34.410 arthritis or not, 02:34.419 --> 02:37.169 it seems to be minor except in a few instances in which I'll talk 02:37.179 --> 02:38.369 about and rejection, 02:38.380 --> 02:41.289 usually what gets the graft and 02:41.300 --> 02:43.960 there's other things that can cause morphological changes in the graph 02:44.509 --> 02:46.190 alluded to the Pacific auto 02:46.830 --> 02:48.110 autograph immunity. 02:48.119 --> 02:50.970 There's no reason that you couldn't form uh circulating H L 02:50.979 --> 02:52.639 A anti H L A antibodies. 02:52.839 --> 02:54.110 And if we're talking about in a minute, 02:54.119 --> 02:56.600 it's not uncommon to see deposits and 02:56.610 --> 02:58.500 graphs who did not have native 02:59.100 --> 02:59.630 arthritis. 02:59.759 --> 03:02.449 And maybe this is an example of a uh autograph 03:02.460 --> 03:04.419 immunity with immune complex disease. 03:04.429 --> 03:07.229 Like you see with some other instances and 03:07.240 --> 03:09.750 also the ischemic change you get in to cloud the 03:09.759 --> 03:11.360 picture somewhat. 03:13.309 --> 03:16.160 The pacific instance in which transmission arthritis 03:16.169 --> 03:18.889 is a real problem are focal sclerosing 03:19.429 --> 03:19.639 opathy. 03:19.649 --> 03:20.080 Again, 03:20.089 --> 03:22.559 I use that you really shouldn't even call it a arthritis. 03:22.570 --> 03:24.369 But we're going to put it in there anyway, 03:24.380 --> 03:26.919 because it's really not an inflammatory process but whether it's 03:26.929 --> 03:27.949 inflammatory or not, 03:27.960 --> 03:29.020 it destroys kidneys. 03:31.179 --> 03:32.029 This is a lady. 03:32.039 --> 03:33.270 Doctor mcfall was talking about, 03:33.279 --> 03:36.160 this is uh a patient of ours had about a 03:36.169 --> 03:38.889 three year history of Nephritic syndrome went into 03:38.899 --> 03:40.860 slowly progressive renal failure. 03:40.889 --> 03:43.600 We went back and looked at her original kidneys and some 03:43.610 --> 03:44.460 original biopsies. 03:44.470 --> 03:46.500 And what we saw was classic focus grows and 03:48.020 --> 03:50.479 the process was focal and segmental. 03:50.490 --> 03:50.639 Here, 03:50.649 --> 03:52.300 you can see the loop looks pretty good, 03:52.470 --> 03:53.919 but you will notice going on here, 03:53.929 --> 03:56.089 there's completely hypo cellar area, 03:56.190 --> 03:57.660 s matrix proliferation, 03:57.669 --> 03:58.910 adhesion to bone capsule. 03:59.309 --> 04:01.720 Here you can see some high 04:02.199 --> 04:05.149 drop at seven deposits and 04:05.160 --> 04:05.820 foam cells. 04:05.830 --> 04:07.779 A classic his focus and the 04:08.699 --> 04:09.750 plus on E M, 04:09.759 --> 04:12.699 she showed the fusion of foot processes which is the other 04:13.139 --> 04:14.529 component of this disease. 04:16.140 --> 04:18.779 This is just a higher P an area of focal 04:18.790 --> 04:19.510 sclerosis. 04:19.730 --> 04:21.609 You can see this part of the loop looks pretty good. 04:21.619 --> 04:22.929 This is the P A S stain. 04:23.230 --> 04:26.049 These sub inter deposits are highland 04:26.059 --> 04:28.290 deposits stand out very nicely. 04:28.299 --> 04:29.820 This is not me matrix. 04:29.829 --> 04:32.720 It does not have a fibular mass matrix and on 04:32.730 --> 04:33.369 silver stain, 04:33.380 --> 04:36.250 this material does not stain silver positive like Messan matrix. 04:37.350 --> 04:39.959 The deposits on E E M correspond to seven or three 04:39.970 --> 04:41.279 electron dense deposits. 04:41.290 --> 04:43.119 The exact nature of which nobody should. 04:45.149 --> 04:47.540 This is an E M on a patient with and, 04:48.429 --> 04:50.529 and from looking at this one field, 04:50.540 --> 04:53.149 it's identical to what you see in Neil's disease. 04:53.420 --> 04:56.250 An opinion of many people who have a lot more experience with E M than I 04:56.260 --> 04:58.429 do like doctors Fargo uh 04:58.440 --> 05:01.100 feel that the presence of diffuse fusion of foot 05:01.109 --> 05:04.100 process is approaching 100% is really found 05:04.109 --> 05:05.329 only in two disease entity, 05:05.339 --> 05:07.670 no matter whether there's neurotic syndrome present or not. 05:07.679 --> 05:09.959 That's Neal's disease and go 05:10.839 --> 05:13.670 what the relationship of and is to Neil's 05:13.679 --> 05:16.029 disease is unknown as a subject unto itself. 05:17.630 --> 05:20.630 This is an example of this lady's graph when it had 05:20.640 --> 05:22.230 to be removed at approximately two months. 05:22.239 --> 05:23.649 Although she had normal renal function, 05:23.660 --> 05:25.880 she had such a horrendous nephritic syndrome. 05:25.890 --> 05:26.459 But clinically, 05:26.470 --> 05:28.779 the graph had to be removed for the benefit of the patient. 05:28.959 --> 05:29.269 Here. 05:29.279 --> 05:29.579 Again, 05:29.589 --> 05:30.649 you can see the reoccurrence, 05:30.660 --> 05:31.339 this peculiar 05:33.679 --> 05:36.619 sclerosis here with some adhesions to Bowman's capsule. 05:36.630 --> 05:37.070 Here. 05:40.720 --> 05:43.309 When you're talking about foot process fusion in the graph, 05:43.320 --> 05:44.309 it comes a little different. 05:44.320 --> 05:47.160 You can get significant fusion of foot process and autograph 05:47.170 --> 05:47.799 rejection. 05:48.089 --> 05:50.890 But at least in Bush's experience in the porters 05:50.899 --> 05:53.089 usually doesn't go beyond 70%. 05:53.579 --> 05:56.100 The Nero syndromes associated with chronic 05:56.109 --> 05:57.000 rejection again, 05:57.010 --> 05:58.709 show diffuse fusion of foot processes, 05:58.809 --> 06:01.739 but they get a massive change in the sub endothelial on 06:01.750 --> 06:02.500 the basement membrane, 06:02.510 --> 06:04.790 which I talked about with you before. 06:04.820 --> 06:07.429 So this lady is showing diffuse fusion of foot 06:07.440 --> 06:10.220 processes 100% without sub endothelial 06:10.230 --> 06:11.709 changes in her basement membrane. 06:11.720 --> 06:13.350 And even though this is in a graph, 06:13.359 --> 06:15.220 I think it's a still pat of focus 06:16.670 --> 06:17.250 on E M. 06:17.420 --> 06:18.769 And then when you combine it with a light, 06:18.829 --> 06:20.190 my there's really no doubt. 06:22.480 --> 06:25.220 And this is just her most recent graph again showing a re 06:25.230 --> 06:27.029 occurrence that peculiar focus crossing. 06:27.850 --> 06:28.579 Fortunately, 06:28.589 --> 06:29.010 this time, 06:29.019 --> 06:31.470 she's not having near as much and she's able to uh 06:31.480 --> 06:32.910 maintain useful function. 06:32.920 --> 06:34.950 Despite the syndrome, 06:37.559 --> 06:39.950 the other entity in which you can see recurrence of 06:40.579 --> 06:41.440 is fairly commonly. 06:41.450 --> 06:44.089 I think the only real big series out of Minnesota five of 06:44.100 --> 06:46.000 nine Children with so called me 06:48.179 --> 06:50.700 has also been called hyper of 06:50.709 --> 06:52.809 childhood reoccurred with the disease. 06:53.450 --> 06:56.160 And they usually show recurrence of the hyper 06:56.769 --> 06:58.859 aia too if they recur with the disease in the ground. 07:00.470 --> 07:02.549 The patient of Doctor mcfall talked about priest. 07:02.559 --> 07:04.619 I really don't have any good slides on, 07:04.630 --> 07:05.559 I took some slides, 07:05.570 --> 07:06.899 but unfortunately, 07:06.920 --> 07:08.839 uh they didn't turn out very well. 07:08.850 --> 07:11.609 But I will show you some examples of me my 07:12.239 --> 07:13.279 in a native kidney, 07:14.010 --> 07:16.459 some people use the term very loosely. 07:16.470 --> 07:19.470 We use a very strict sense and it is a disease in which 07:19.480 --> 07:21.980 you get massive with beginning 07:22.250 --> 07:22.720 libation, 07:22.859 --> 07:24.200 massive enlargement of the. 07:24.579 --> 07:25.089 As you see, 07:25.100 --> 07:28.040 here are 2 to 3 times normal size and some degree 07:28.049 --> 07:29.380 of thickening the basement membrane, 07:29.390 --> 07:30.940 which may or may not show splitting. 07:33.149 --> 07:35.320 This is another example of me, 07:36.000 --> 07:37.579 you see the mark lobulation, 07:37.589 --> 07:38.959 increased massage matrix. 07:39.160 --> 07:40.329 And as you can appreciate here, 07:40.339 --> 07:42.730 this one here is the type that's showing the 07:42.739 --> 07:45.730 splitting of the basement membrane due to massage in 07:45.750 --> 07:46.299 position. 07:48.100 --> 07:50.730 Here you can see the splitting of the basement 07:50.739 --> 07:51.309 membrane. 07:51.559 --> 07:51.760 Now, 07:51.769 --> 07:54.019 when this disease reoccurs in the graph, 07:54.390 --> 07:57.160 just the presence of splitting the basement membrane is not significant to 07:57.170 --> 08:00.160 make it uh sufficient to make a diagnosed meno poly 08:01.170 --> 08:04.079 circumferential mas inter position is very common in 08:04.089 --> 08:04.440 graphs. 08:04.450 --> 08:04.799 I'm sorry, 08:04.809 --> 08:07.519 I didn't get through to the ems this morning on the graph changes. 08:07.529 --> 08:09.450 After you get that change, 08:09.459 --> 08:11.869 the next change you can go into is a 08:11.880 --> 08:14.519 circumferential masang inter position and chronic graph 08:14.529 --> 08:15.160 rejection. 08:15.420 --> 08:17.970 So you've got to see the overall changes it should be marketed, 08:18.065 --> 08:20.695 enlargement of the the prominent 08:20.704 --> 08:23.674 lobulation as well as the basement membrane changer before you 08:23.684 --> 08:25.424 can make a diagnosis of current me 08:26.695 --> 08:29.385 in contrast to the sang and peripheral basement 08:29.394 --> 08:30.065 membrane change, 08:30.075 --> 08:32.885 you can get in just chronic vascular rejection without 08:32.895 --> 08:34.875 any underlying immunological problem. 08:36.690 --> 08:36.710 Now, 08:36.719 --> 08:39.380 this is an example of me Riis 08:40.150 --> 08:43.030 here is the original basement membrane here here would 08:43.039 --> 08:44.030 be the urinary space. 08:44.039 --> 08:46.500 Here is the what happens in these 08:46.590 --> 08:47.419 people. 08:47.429 --> 08:48.190 For some reason, 08:48.200 --> 08:50.940 the cell grow out under the 703 08:51.250 --> 08:53.750 market thicken it and then lay down a new lamb. 08:54.119 --> 08:56.570 It's usually a little thinner than the original lama dens. 08:56.669 --> 08:59.539 A very similar morphology can occur in 08:59.869 --> 09:00.599 graph rejection. 09:00.609 --> 09:01.690 So by alone, 09:01.830 --> 09:03.679 you really can't make the diagnosis of the current meris. 09:07.520 --> 09:10.390 Some of these people are memoli instead of showing a 09:10.400 --> 09:12.260 thickening of splitting the base membrane, 09:12.270 --> 09:15.210 they will show show so called electron dense 09:15.219 --> 09:16.020 deposits. 09:16.179 --> 09:19.039 And one time this was separated out of the so called electron 09:19.049 --> 09:20.500 dense deposit disease. 09:21.190 --> 09:23.340 But doctor B in France, 09:23.349 --> 09:25.919 I think most people now feel this is nothing more than just in the 09:25.929 --> 09:28.840 spectrum of variant of memos and 09:28.849 --> 09:31.559 this particular variant of memoli nephritis. 09:31.890 --> 09:34.869 The electron deposit disease seems to be even 09:34.880 --> 09:37.330 more likely to re occur almost 100%. 09:37.719 --> 09:40.380 And the French experience than the other form of me, 09:41.030 --> 09:42.820 the thing is this is so rare. 09:42.830 --> 09:43.770 You'll probably never see it. 09:43.780 --> 09:46.489 We've only seen one case I know of in any 09:46.500 --> 09:47.039 disease. 09:47.049 --> 09:48.619 Kidney in the four or five years, 09:48.630 --> 09:50.239 I've been at Hall the Kidney Bobs. 09:51.760 --> 09:54.700 I told you that the problem that comes up with trying to diagnose with chronic 09:55.330 --> 09:57.979 arthritis in the graph is a confusion that you run into with the 09:57.989 --> 10:00.929 same changes that apparently can occur with chronic 10:00.940 --> 10:03.929 rejection without an underlying immm basis 10:03.940 --> 10:06.549 immune complex or anti GB M process. 10:06.960 --> 10:09.859 This is a kidney of a five year old 10:09.869 --> 10:12.479 boy who had well documented dysplastic kidney 10:12.489 --> 10:13.270 disease. 10:13.280 --> 10:16.140 He had his original native kidneys removed at a very young age. 10:16.150 --> 10:18.919 He had nothing to suggest any type of underlying 10:18.929 --> 10:21.539 immunological problem over the next couple of 10:21.549 --> 10:21.960 years, 10:21.969 --> 10:24.559 he went into chronic vascular rejection at the time of 10:24.570 --> 10:25.409 autopsy. 10:25.429 --> 10:28.409 Those previous dark slides showed a tremendous 10:28.570 --> 10:31.340 some sang thickening and widespread thickening 10:31.349 --> 10:33.940 memories changed the basement membrane as well as widespread 10:34.080 --> 10:35.793 split in the basement membrane. 10:35.903 --> 10:38.773 But in contradistinction to me politic arthritis, 10:38.822 --> 10:41.612 those were shrunken retracted, 10:41.793 --> 10:44.523 they looked a trophic as well as showing these other changes I 10:44.533 --> 10:47.213 talked about and minopoli the is 10:47.223 --> 10:48.182 marked and large, 10:48.192 --> 10:51.143 sometimes three and four times the diameter of a 10:51.153 --> 10:51.632 normal. 10:52.083 --> 10:54.783 And I think that's part of the best way to differentiate 10:54.793 --> 10:57.263 between the memo type change you can get is a 10:57.463 --> 11:00.333 chronic rejection phenomena from those 11:00.343 --> 11:03.176 of the true recurrent memo plus the 11:03.185 --> 11:06.026 correlation of clinical and I fluorescent data. 11:06.106 --> 11:08.885 But this is this child at the time of death. 11:08.895 --> 11:11.176 You can see he does have typical 11:11.216 --> 11:14.106 widespread splitting of the basement membrane and he 11:14.116 --> 11:17.036 also has circumferential mass and positioning 11:17.116 --> 11:20.056 very similar to what we saw in that well documented 11:20.065 --> 11:20.515 case of me, 11:22.056 --> 11:23.645 he does not have deposits, 11:23.656 --> 11:26.265 the ones with me commonly will have 11:26.276 --> 11:29.106 deposits but they can be somewhat focal 11:29.116 --> 11:29.526 and may, 11:29.536 --> 11:30.385 you may miss them 11:34.429 --> 11:37.080 another disease entity that Doctor mcfall doesn't 11:37.090 --> 11:37.640 mention. 11:38.210 --> 11:39.140 And we have not, 11:39.150 --> 11:39.289 well, 11:39.299 --> 11:42.150 we have had some recurring anti GB MS but they really 11:42.159 --> 11:44.830 haven't expressed themselves moral to the patient. 11:44.840 --> 11:47.640 Went ahead and lost his graph because of rejection. 11:47.760 --> 11:49.130 But in early work of Dixon, 11:49.140 --> 11:52.080 he did have at least one rapidly 11:52.090 --> 11:52.409 progress. 11:52.950 --> 11:55.929 Arthritis re occur within the first couple of days of transplantation due 11:55.940 --> 11:58.239 to anti GB M arthritis. 11:58.429 --> 12:00.400 And this is just an example of good pastures. 12:00.409 --> 12:01.570 And the point I wanna make here, 12:01.580 --> 12:02.940 this is not in a graph. 12:02.950 --> 12:04.940 If you ever see this degree of crescent 12:04.950 --> 12:06.799 formation in a graft, 12:07.020 --> 12:09.700 you can be almost absolutely sure that that 12:09.710 --> 12:11.760 patients got recurrence of arthritis. 12:11.770 --> 12:14.739 Crescents are just not prominent and graft rejection 12:14.750 --> 12:17.159 of any type either hyper acute, 12:17.179 --> 12:18.119 acute or chronic. 12:18.130 --> 12:20.510 You may see a few scattered small crescents, 12:20.520 --> 12:23.460 but crescents of this size are just almost half of the mo 12:23.700 --> 12:25.510 or occurring to mars in the ground. 12:26.890 --> 12:27.869 And this is not again, 12:27.880 --> 12:28.580 it's not a graph, 12:28.590 --> 12:29.539 it's just a good, 12:29.549 --> 12:30.570 good pastures. 12:30.580 --> 12:33.450 But the original case of Dixon did reoccur with a 12:33.460 --> 12:35.059 morphology identical to this 12:38.520 --> 12:41.510 and this is a case of just how you 12:41.520 --> 12:43.929 might work up a a problem of the 12:43.940 --> 12:46.059 current arthritis. 12:46.530 --> 12:48.309 This patient and his graft 12:49.599 --> 12:51.190 in about six months or one year. 12:51.200 --> 12:51.729 I'm not sure. 12:51.739 --> 12:53.830 Now showed some degree of sang 12:54.020 --> 12:56.929 proliferation masang thickening as you can see here 12:57.109 --> 13:00.049 and all of these changes can occur as a part of a graph 13:00.059 --> 13:00.630 rejection. 13:00.640 --> 13:02.489 So how are you gonna try to separate them out? 13:02.859 --> 13:03.020 Well, 13:03.030 --> 13:05.640 one thing is to look around and see what are the vascular 13:05.650 --> 13:06.830 changes using? 13:06.840 --> 13:09.424 The cha changes in the due to rejection 13:09.434 --> 13:11.924 always less severe than those in the vessels. 13:11.934 --> 13:14.835 If you look in the vessels look pretty clean and yet 13:14.844 --> 13:17.094 your is showing this degree of proliferation, 13:17.265 --> 13:18.974 you really got to start thinking about Ken, 13:19.015 --> 13:21.924 does this guy have recurrent glome arthritis 13:21.934 --> 13:24.684 or at least part of this problem due to recurrent arthritis. 13:26.150 --> 13:28.349 We did E M on this particular case 13:30.710 --> 13:30.750 here. 13:30.760 --> 13:32.280 This is a basement membrane. 13:32.289 --> 13:34.900 Here you see these electron dense deposits. 13:34.909 --> 13:35.440 This is his, 13:35.559 --> 13:37.080 I mean this is his graph, 13:37.429 --> 13:40.179 you can get varying degrees of deposits and the G 13:40.609 --> 13:42.109 is a part of rejection to that again, 13:42.119 --> 13:44.080 that makes the process difficult. 13:44.090 --> 13:45.250 But our experience, 13:45.770 --> 13:48.609 we just don't see this type of the type of immune 13:48.619 --> 13:51.619 complex electron dense deposits very often and she 13:51.719 --> 13:53.530 have been correlated with arthritis 13:55.260 --> 13:57.700 if you go back and look at his original kidney. 13:58.400 --> 13:59.510 This is one that I didn't, 13:59.520 --> 14:00.469 I don't have pictures of it. 14:00.479 --> 14:02.380 But until you go back and look at the original kidney, 14:02.390 --> 14:05.090 you see he does have this is kind of a non specific sri 14:06.630 --> 14:07.409 in this case. 14:07.719 --> 14:08.289 But you know, 14:08.299 --> 14:09.729 you look at his native kidney. 14:09.919 --> 14:12.729 Doctor mcfall tells you he had on his native 14:12.739 --> 14:13.299 kidney. 14:13.570 --> 14:16.320 And then sometimes if you have ems on his native kidney, 14:16.330 --> 14:19.239 you had deposit some of those in the graph that pretty much seals the 14:19.250 --> 14:20.119 diagnosis. 14:20.559 --> 14:20.700 Well, 14:20.710 --> 14:21.260 in this case, 14:21.270 --> 14:23.770 we didn't have E M but sometimes you can take the blocks out of 14:24.030 --> 14:25.049 which we did here. 14:25.900 --> 14:28.770 And we were able to demonstrate that in his native kidney 14:29.070 --> 14:30.549 on paraffin embedded material, 14:30.559 --> 14:31.760 we were able to demonstrate again, 14:31.770 --> 14:34.760 electron dense deposits that have identical location 14:34.770 --> 14:37.099 in the basement membrane to the deposits that he's 14:37.109 --> 14:38.500 manifested in his graph 14:40.169 --> 14:41.419 here is not quite as good. 14:41.429 --> 14:42.929 This was paraffin embedded material. 14:42.940 --> 14:43.940 I know that's not very good, 14:43.950 --> 14:45.349 but considering it's coming from paraffin, 14:45.580 --> 14:48.539 it's it's uh not bad and especially you can make out the 14:48.549 --> 14:50.419 electron dens deposits right in trouble. 14:50.429 --> 14:51.270 So in this case, 14:51.280 --> 14:54.010 by doing a little detective work in correlation clinically and Doctor 14:54.020 --> 14:56.400 mcfall is helping I help him with E M and 14:56.969 --> 14:59.340 you could pretty well establish this guy did have some 14:59.349 --> 15:01.599 degree of recurrent arts. 15:01.840 --> 15:04.299 But I would predict that if this guy loses his graft, 15:04.309 --> 15:06.340 he'll most likely lose it because of rejection, 15:06.349 --> 15:08.369 not really because of the recurrent arthritis. 15:11.599 --> 15:13.969 And we just talked about previously this morning, 15:13.979 --> 15:16.799 the changes you see as part of graph rejection that can be 15:16.809 --> 15:18.409 confused with current fires. 15:18.539 --> 15:21.440 This is a typical change you see in 15:21.450 --> 15:22.090 rejection. 15:24.119 --> 15:26.200 And we've already talked about this memin change. 15:26.210 --> 15:28.729 You can see as part of chronic graph rejection which should not be 15:28.739 --> 15:31.020 mistaken for memin arthritis. 15:36.280 --> 15:38.559 I think what I'm trying to point out is right here. 15:38.809 --> 15:41.400 This is another biopsy an E M done on a 15:41.409 --> 15:44.169 graph and a patient that had documented uh dysplastic 15:44.179 --> 15:46.729 kidneys had no reason to have immune complex uh 15:46.739 --> 15:49.690 anti GB M arthritis in his graph on 15:49.700 --> 15:50.099 E E M. 15:50.109 --> 15:52.000 Although his was negative, 15:52.010 --> 15:54.809 he demonstrated some sub electron dense 15:54.820 --> 15:55.580 deposits. 15:55.830 --> 15:58.552 This is these type of closes that they 15:58.562 --> 15:59.973 look different from a classic. 16:00.143 --> 16:00.833 You seen a cut. 16:01.963 --> 16:04.263 I really don't know what their significance is. 16:04.273 --> 16:05.872 I think are very non specific, 16:05.882 --> 16:08.843 but they are seen fairly commonly in graphs. 16:08.853 --> 16:11.713 They were seen in 10 of 45 of the graphs in series in 16:11.723 --> 16:14.723 which he did E M and they occur where the patient had native 16:15.122 --> 16:15.963 fire or not. 16:16.033 --> 16:18.976 So I would just warn you on articles that are published and 16:18.986 --> 16:21.885 show a few deposits like that and try to push that 16:21.895 --> 16:23.486 off as fires. 16:23.796 --> 16:26.656 I think that may well be debris or it may, 16:26.666 --> 16:29.625 it might actually be a manifestation of a de novo 16:30.216 --> 16:32.716 uh arthritis related to uh 16:32.926 --> 16:35.835 things not transplant fires or 16:35.846 --> 16:37.635 histocompatibility change. 16:37.645 --> 16:39.476 But there's just really no way of knowing at present 16:40.520 --> 16:42.940 morphology of recurrent disease and 16:42.950 --> 16:45.619 transplantation with James D 16:45.630 --> 16:48.169 Mullin's Major US Air Force Medical Corps, 16:48.179 --> 16:50.950 Wilford Hall US Air Force Medical Center, 16:50.979 --> 16:52.469 Lackland Air Force Base 16:54.440 --> 16:57.190 was produced through the mobile facilities of the television 16:57.200 --> 16:57.849 division, 16:57.890 --> 16:59.299 Academy of Health Sciences, 16:59.309 --> 17:01.309 United States Army Fort Sam. 17:01.320 --> 17:01.820 Houston, 17:01.830 --> 17:02.489 Texas.