Society of Diabetic Nephropathy Prevention Journal of Nephropathology 2251-8363 6 4 2017 10 01 "Fish-scales" and graft nephrectomy: unexpected findings at an unusual site 349 351 10.15171/jnp.2017.56 EN Smiley Annie George Issam Francis Journal Article 10.15171/jnp.2017.56 2017 02 17 2017 06 23 Background: Kayexalate and sevelamer are resin medications commonly used in the setting of chronic renal failure for the treatment of hyperkalemia and hyperphosphatemia respectively, are known to cause bowel ischemia, ulcerations, necrosis, pseudotumors and perforations and the incidence is higher after post-transplant. Herein we report its presence on the surface of a graft nephrectomy following a masked intestinal perforation. underwent graft nephrectomy due to wound infection, peri-graft collection and risk of hemorrhage from the vascular anastomotic site. Histological evaluation showed extensive acute tubular necrosis and peri-renal abscess with vegetable matter and numerous colored crystals morphologically consistent with kayexalate and sevelamer. The possibility of an underlying resin induced intestinal perforation was rendered. could be a clinical emergency and a high index of suspicion particularly in a post-transplant setting may allow prompt recognition and surgical cure. From the pathologists’ view familiarity with the morphological appearances of these non-systemic resin medications and its histologic mimics enables accurate diagnosis and timely clinical intervention.