A 30-year-old woman was admitted to the University of Minnesota Hospital to receive a second cadaveric renal transplant. Eighteen years earlier, she had received her first cadavenc renal transplant for renal failure due to chronic glomerulonephritis. She had been dialyzed for 4 months, during which time she underwent splenectomy and bilateral nephrectomy. Tissue from the latter procedure demonstrated end-stage renal disease consistent with chronic glomerulonephritis. She was treated with azathioprine, 100 mg/day, and prednisone, 20 mg/day, as a maintenance regimen initially; within one year, the prednisone dose was reduced to 10mg daily. The patient's first renal aflograft functioned well for several years; the serum creatinine concentration ranged between 0.9 mg/dl and 1.1 mg/dl. Eleven years ago, the serum creatinine concentration rose to 2.9 mg/dl over 2 months; a graft biopsy demonstrated acute tubulointerstitial rejection. The patient admitted to noncompliance with her immunosuppressive regimen over several weeks. The prednisone dosage was increased to 100 mg/day and then tapered over the succeeding one month to 15 mg/day; the serum creatinine concentration stabilized at 1.6 mg/dl. Because of a rise in the serum creatinine concentration to 2.0 mg/dl, a graft biopsy was repeated 5 years ago. The biopsy specimen demonstrated chronic tubulointerstitial rejection and focal scarring with changes of chronic vascular rejection. The immunosuppressive regimen was continued, but propranolol, 20 mg twice daily, was begun because of hypertension. Subsequently, the dose of propranolol was increased to 40 mg twice daily; her blood pressure was controlled at approximately 135/85 mm -Hg. Because of a subsequent rise in the serum creatinine concentration to 2.5 mg/dl 3 years prior to admission, the