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Kidney non-tumor

Kidney transplantation

Chronic rejection

Reviewers: Nikhil Sangle, M.D. (see Reviewers page)
Revised: 25 December 2012, last major update September 2012
Copyright: (c) 2003-2012, PathologyOutlines.com, Inc.


● Also called chronic allograft nephropathy, interstitial fibrosis and tubular atrophy not otherwise specified
● Irreversible end stage of repeated episodes of acute vascular or interstitial rejection
● Occurs months to years after transplantation, independent of acute rejection and specific disease
● Incidence of 55% after 8 years post-transplant in one study (Nephrol Dial Transplant 2011;26:3750)
● Most common cause of graft failure after 6-12 months


● Transplant arteriopathy/capillaropathy and glomerulopathy are induced by alloantigens - systematic assessment of longitudinal changes in alloantibody levels can identify patients at greater risk (Kidney Int 2011;79:1131)
● Inflammation (due to various causes) and tissue remodeling may induce autoimmune responses against self-antigens, leading to chronic rejection (Discov Med 2010;9:229)

Gross images

Enlarged kidney with surface hemorrhage

Micro description

Chronic transplant nephropathy: non-specific sclerosing changes (no lesions indicative of immunologic injury, thus a diagnosis of exclusion)
● Resembles nephrosclerosis
● Severe obliterative fibrointimal proliferation or mucoid widening of intima
● Reduplication or disruption of elastic lamina and irregular fibrosis of media
● Variable distribution of vascular lesions; also occasional small thrombi
● Atrophic tubules, diffusely scarred interstitium
● Glomerulosclerosis with ischemic glomerular capillary collapse and thickened capillary walls
Transplant capillaropathy: peritubular capillary profile with 7+ circumferential basement membrane layers or 3 profiles with 5-6 circumferential layers; these findings are specific (except for obstructive uropathy or thrombotic microangiopathy) and sensitive (present in 80%) for chronic rejection; may be due to repeated episodes of endothelial cell damage or death and regeneration

Micro images

Various images

Virtual slides

Chronic rejection


● Negative, occasional linear or granular deposition of IgM, IgG or complement

Electron microscopy description

● Thickened capillary walls due to widening of subendothelial space or mesangial interposition
● Electron microscopy better than light microscopy to identify microvascular changes (Mod Pathol 2001;14:1200)

Electron microscopy images

Transplant capillaropathy: various images

End of Kidney non-tumor > Kidney transplantation > Chronic rejection

Ref Updated: 9/4/12

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