A 67-year-old woman who had a heart transplant 3 years earlier presented for a routine heart biopsy in normal health.
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Antibody mediated rejection, pAMR1 (H+).
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In 2013, the ISHLT instituted a new nomenclature for pathologist-directed diagnosis of AMR, termed pAMR. This case has the classic histomorphometric appearance of AMR as described in our AMR tutorial. Namely there is a "busy B" pattern at low power and at high power significant numbers of intravascular mononuclear cells are seen. Interestingly for this patient, complement staining for C3d and C4d was negative. A DSA was not elevated, although there was increased cross-reactivity to more HLAs. Thus, the best diagnosis for the patient is pAMR1 (H+). This is not always treated the same as AMR that causes positive C4d and C3d staining.
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