Diagnostic significance of peritubular capillary basement membrane multilaminations in kidney allografts: old concepts revisited

Transplantation. 2012 Sep 27;94(6):620-9. doi: 10.1097/TP.0b013e31825f4df4.


Background: Injury to peritubular capillaries and capillary basement membrane multilamination (PTCL) is a hallmark of antibody-mediated chronic renal allograft rejection. However, the predictive diagnostic value of PTCL is incompletely studied.

Methods: We analyzed the diagnostic significance of PTCL and propose diagnostic strategies. We evaluated 360 diagnostic native and 187 transplant kidney specimens by electron microscopy (terminology: PTCL-C, severe; PTCL subgroup C3, very severe multilamination; see Materials and Methods for definitions).

Results: PTCL was not pathognomonic for any specific disease. PTCL-C/C3 was rare in native kidneys (C, 6%; C3, 1%), associated mainly with late thrombotic microangiopathy (C: 78%; C3: 11% of cases). In allografts, PTCL-C/C3 was significantly more common, especially in specimens more than 24 months after transplantation (C, 47%; C3, 31%). PTCL-C/C3 was found in acute (C, 20%; C3, 7%) and chronic T-cell rejection (C, 67%; C3, 29%), calcineurin inhibitor toxicity (C, 36%; C3, 18%), or C4d(+) specimens (C, 61%; C3, 50%) with odds ratios between 4 and 36. PTCL-C3 was more predominant in cases with antibody-mediated injury. Highest odds ratios (81-117) for PTCL-C/C3 were noted in combined injuries, that is, mixed chronic T-cell and concurrent chronic antibody-mediated rejection. Positive predictive values of PTCL-C and C3 are the following: all rejection types, 89% and 93%; all Banff chronic rejection types, 69% and 71%; and chronic presumptive antibody rejection, 37% and 49%, respectively. Corresponding negative predictive values of C and C3 for different Banff rejection categories are between 50% and 94%.

Conclusions: The presence of PTCL-C3 is a helpful adjunct finding to diagnose rejection-induced tissue injury but cannot precisely predict the Banff rejection category. Conversely, the absence of PTCL-C3 is helpful in excluding chronic, Banff category II antibody-mediated rejection.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Capillaries / immunology
  • Capillaries / ultrastructure*
  • Chronic Disease
  • Glomerular Basement Membrane / immunology
  • Glomerular Basement Membrane / ultrastructure*
  • Graft Rejection / blood
  • Graft Rejection / etiology
  • Graft Rejection / immunology
  • Graft Rejection / pathology*
  • Humans
  • Isoantibodies / blood
  • Kidney Glomerulus / blood supply*
  • Kidney Glomerulus / immunology
  • Kidney Glomerulus / ultrastructure*
  • Kidney Transplantation / adverse effects*
  • Kidney Transplantation / immunology
  • Logistic Models
  • Microscopy, Electron
  • Observer Variation
  • Odds Ratio
  • Predictive Value of Tests
  • Reproducibility of Results
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Time Factors
  • Treatment Outcome


  • Isoantibodies