title: Current problems of chronic active antibody-mediated rejection.
abstract: The Banff 2007 classification allows chronic rejection to be differentiated based on clinicopathological characteristics evidenced by two independent immunologic mechanisms; chronic active antibody-mediated rejection and chronic active T-lymphocyte mediated rejection. However, several incompletely understood issues concerning chronic active antibody-mediated rejection remain. Chronic active antibody-mediated rejection is characterized by C4d deposition in the capillary basement membrane(PTC), the presence of circulating anti-donor antibodies(DSA), and morphologic evidence of chronic tissue injury such as glomerular double contours compatible with transplant glomerulopathy (TPG), PTC basement membrane multilayering, interstitial fibrosis/tubular atrophy, and fibrous arterial intimal thickening. PTC basement membrane multilayering correlates highly with TPG, and most of TPG have evidence of either C4d-positive staining or DSA. However, the proposed criteria do not apply to all situations of chronic active antibody-mediated rejection. C4d is not a magic marker for antibody-mediated rejection. C4d staining is not always highly sensitive for detecting antibody-mediated rejection. Multi-institutional studies should be conducted to better understand the clinicopathological context of chronic antibody-mediated rejection. These studies should include well-designed serial protocol biopsies with evaluation by electron microscopy, C4d staining performed on frozen sections, and assessment using sensitive DSA detection methods.
authors.affiliation: Japanese Red Cross Nagoya Daini Hospital, Department of Nephrology, Nagoya, Japan.
authors.forename: Asami
authors.initials: A
authors.lastname: Takeda
authors.forename: Keiji
authors.initials: K
authors.lastname: Horike
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Ohtsuka
authors.forename: Daijo
authors.initials: D
authors.lastname: Inaguma
authors.forename: Norihiko
authors.initials: N
authors.lastname: Goto
authors.forename: Yoshihiko
authors.initials: Y
authors.lastname: Watarai
authors.forename: Kazuharu
authors.initials: K
authors.lastname: Uchida
authors.forename: Kunio
authors.initials: K
authors.lastname: Morozumi
mesh_terms: D000888:Antibodies, Anti-Idiotypic / Q000276:immunology*; D015935:Complement C4b / Q000276:immunology*; D006084:Graft Rejection / Q000276:immunology*; D006801:Humans; D016030:Kidney Transplantation / Q000276:immunology*; D010446:Peptide Fragments / Q000276:immunology*; D014019:Tissue Donors
chemical_list: D000888:Antibodies, Anti-Idiotypic; D010446:Peptide Fragments; D015935:Complement C4b; C032261:complement C4d