Table 1.

Antibody-mediated renal transplant pathologya

DiagnosisClinical PresentationHistologyC4dSerologyOutcome
Hyperacute rejectionImmediate graft failure (minutes to hours) after reperfusionNeutrophils in glomeruli and PTC; hemorrhage, necrosis, thrombosisPositive PTC; may be negative earlyAnti-donor HLA or ABO positive in majorityAlmost always irreversible
Acute humoral rejectionRapid loss of graft function (days), any time after transplantationVariable. Neutrophils and macrophages in glomeruli and PTC; fibrinoid arterial necrosis, acute tubular injury; ± cell-mediated rejectionPositive PTC; variable glomeruliAnti-donor HLA (class I and/or II) or ABO positive in majority (approximately 90%)Often reversible with appropriate treatment
Chronic humoral rejectionSlow, progressive loss of graft function (months to years), often with proteinuria, hypertensionGBM duplication; mononuclear cells in glomeruli and PTC; intimal fibrosis; tubular atrophy and interstitial fibrosis; PTC basement membrane multilamination (by EM)Positive PTC (often patchy); glomeruli variably positive; occasionally only glomeruli positiveAnti-donor HLA positive in majority, especially to MHC class II antigens.Outcome and optimal therapy not yet defined
AccommodationNormal graft functionNormal, or minor changesPositive PTC; variable glomeruliCommon with ABO incompatibility; occasionally with HLA antibodiesOutcome and optimal therapy not yet defined
  • a EM, electron microscopy; GBM, glomerular basement membrane; PTC, peritubular capillary.