A renal transplant recipient presents 6 years after transplantation with slowly rising creatinine and worsening proteinuria. Biopsy shows concentric intimal thickening of allograft arteries with luminal narrowing, interstitial fibrosis and tubular atrophy, without acute cellular infiltrates. What is the diagnosis?

• A Chronic allograft nephropathy due to transplant arteriopathy ✓
• B Chronic antibody-mediated rejection with transplant glomerulopathy
• C Acute T-cell mediated rejection, Banff IIA
• D Thrombotic microangiopathy secondary to calcineurin inhibitor toxicity

Explanation

Chronic rejection manifests as transplant arteriopathy: proliferative intimal thickening of arteries by smooth muscle cells and fibroblasts, producing ischaemic interstitial fibrosis and tubular atrophy over months to years. Acute cellular rejection shows tubulitis and interstitial lymphocytic infiltrates, which are absent here. Calcineurin inhibitor toxicity produces arteriolar hyalinosis and striped fibrosis rather than concentric arterial intimal proliferation.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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