Eosinophil involvement in renal allograft rejection was elucidated with immunocytochemical techniques. Sections of renal biopsies were stained for immunoreactive eosinophils and extracellular deposits of eosinophil cationic protein (ECP). Activated eosinophils were identified by means of alkaline-phosphatase-linked monoclonal antibodies. In biopsies from patients with acute rejection of the interstitial type, a varying degree of eosinophil infiltration in the interstitium was seen. Minor extracellular deposits of ECP were present in areas with activated eosinophils. In acute vascular rejection, dense infiltration of activated eosinophils and secreted ECP were found in infarcted areas and in arterial walls with necrotic lesions. Dense accumulation of activated eosinophils and extracellular deposits of ECP were also seen in biopsies from non-transplanted patients with necrotizing renal vasculitides. These findings suggest that cytotoxic eosinophil granule proteins are involved in vascular injury in renal graft rejection and in necrotizing renal vasculitides. Eosinophil activation may also have a pathophysiological role in the interstitial lesions in renal graft rejection.