A renal transplant recipient develops slowly progressive graft dysfunction over 4 years. Biopsy shows concentric intimal thickening of arteries with luminal narrowing and patchy interstitial fibrosis. This lesion represents:
- A Hyperacute rejection due to preformed anti-donor antibodies
- B Chronic rejection with transplant arteriopathy ✓
- C Calcineurin inhibitor induced thrombotic microangiopathy
- D Acute cellular rejection with tubulitis
Correct answer: B. Chronic rejection with transplant arteriopathy
Explanation
Chronic rejection manifests months to years after transplant as transplant vasculopathy: proliferative intimal thickening of arteries driven by smooth muscle proliferation from a combination of cellular and antibody mediated injury, leading to ischaemia and interstitial fibrosis. Hyperacute rejection is an immediate event with thrombosis and necrosis, not slow arterial remodelling, which kills that distractor. Calcineurin toxicity shows striped interstitial fibrosis without arteriopathy.
Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.
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