Perforin (P) is a cytolytic molecule expressed in the granules of cytolytic T cells and natural killer cells. Although cytotoxic cells have been implicated in graft rejection, no prospective clinical study has been published that examines the dynamics of perforin expressing cells in peripheral blood lymphocytes of transplanted patients. The cytofluorimetric assay developed in our laboratory previously for the simultaneous detection of intracellular perforin together with cell surface molecules was used for posttransplantation monitoring of patients, for the assessment of the efficiency of immunosuppressive treatment, and for the prediction of acute kidney transplant rejection and the stability of tolerance to long lived kidney transplants. Immunosuppression for the purpose of allotransplantation causes a decline in the number of perforin-expressing cells in peripheral blood. In contrast, in patients with clinical signs of acute rejection, the total number of perforin-expressing lymphocytes was increased in comparison with nonrejecting patients. Analyzing perforin-expressing subsets, rejection crises were accompanied by a relative decrease of perforin expression in the CD4+ subpopulation while increasing in the CD8+ subset. In the CD56+ and CD16+ NK subpopulations changes in perforin expression were mixed. In nonrejecting patients the ratio of perforin expression in CD4+ cells was high compared with CD8+ cells. Intensive therapy of acute rejection episodes with high doses of corticosteroids (methylprednisolonet [Solumedrol] bolus) strongly and significantly decreased the percentage of both, the subpopulations of perforin-positive T cells and the subpopulation of CD56+P+ NK cells. The lowest level of perforin expression, including low frequencies of perforin among CD8+ and CD4+ cells, was found in the group of patients tolerating transplanted kidneys for several years. These changes in perforin protein expression in peripheral blood can be used to discriminate between immunosuppressed patients who are immunologically quiescent and those who undergo transplant rejection. Our results confirm the hypothesis that cytotoxicity mediated by perforin may be an important effector mechanism in the rejection of allografted kidneys.