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Chronic renal allograft nephropathy

Daniel C Brennan, MD, FACP
Section Editor
Barbara Murphy, MB, BAO, BCh, FRCPI
Deputy Editor
Albert Q Lam, MD


Renal allograft failure is one of the most common causes of end-stage renal disease (ESRD), accounting for 25 to 30 percent of patients awaiting renal transplantation. Similarly, over 20 percent of kidney transplants performed in the United States go to patients who have failed one or more renal allografts.

The most common cause of graft failure after the first year is an incompletely understood clinicopathological entity variously called chronic rejection, transplant nephropathy, chronic renal allograft dysfunction, transplant glomerulopathy (TG), chronic allograft injury, or chronic renal allograft nephropathy [1-10].

The revised Banff 2005 classification system, which was reported in 2007, renamed chronic allograft nephropathy, "interstitial fibrosis and tubular atrophy (IF/TA), without evidence of any specific etiology" [11]. This was done because the term "chronic allograft nephropathy" was thought to diminish attempts to determine the underlying cause of the histologic lesions.

The Banff 2005 classification also added the category "chronic active antibody-mediated rejection (AMR)" as a subset of AMR. It is characterized by C4d+, presence of circulating anti-donor antibodies, and morphologic evidence of chronic tissue injury, such as glomerular double contours and/or peritubular capillary basement membrane multilayering and/or IF/TA and/or fibrous intimal thickening in arteries.

In the Banff 2013 classification, the requirement for C4d staining for the diagnosis of acute/active and chronic active AMR was replaced by histologic evidence of antibody interaction with the endothelium [12]. Such evidence could include positivity, moderate microvascular inflammation, or increased gene expression suggestive of endothelial injury. Importantly, the Banff group recognized the existence of C4d-negative AMR.

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Literature review current through: Nov 2017. | This topic last updated: Sep 06, 2016.
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