Electron microscopic peritubular capillary lesions: a new criterion for chronic rejection

Typical chronic rejection showing prominent glomerular and/or arterial lesions is less common in renal allograft patients treated with cyclosporin A (CsA). We investigated the value of peritubular capillary lesions as a criterion for chronic rejection in the CsA era. A total of 129 renal graft biopsies, taken from recipients showing graft dysfunction after more than 2 months post-operatively, were examined by electron microscopy, and peritubular capillary lesions were studied, especially multi-layered basement membrane lesions (MLPTC). Eighty-two biopsy specimens taken from non-transplantation patients were also studied as a control. Five biopsies (6%) showed mild and atypical MLPTC in the control group. Of the 129 allograft biopsies, MLPTC was seen in 55 (42.6%). The prevalence showed no significant relationship to the interval from operation to biopsy. MLPTC was either typical (n = 10) or incomplete (n = 45). Concomitant membrane disruption, edema and lymphocyte infiltration of the subendothelial space, reflecting acute cellular rejection, were occasionally noted in both groups. Incomplete MLPTC often developed within 1 yr after surgery, in association with acute rejection. It was found in 26-50% of biopsies at any time up to 5 yr post-operatively. The incidence of typical MLPTC was 5.7-12.8% over 1 yr post-operatively. These findings suggest that the development of chronic rejection is closely related to relapsing acute tubulo-interstitial allograft rejection which is often clinically silent. We concluded that MLPTC is useful as a specific criterion for chronic rejection.