The kidney is very susceptible to hypoxic injury. Calcineurin inhibitors (CNIs) induce vasoconstriction and might reduce renal tissue oxygenation. We aimed to investigate if the synergistic deleterious effects of CNI-treatment and hypoxia of high altitude living might accelerate the development of arteriolar hyalinosis in kidney allografts. We stratified all patients who received a kidney graft from 2000 to 2010 in our center (N = 477) in 3 groups according to the residential elevation (below 400, between 400 to 600 and above 600 m above sea level) and we retrospectively re-evaluated all transplant biopsies performed during follow-up specifically looking at the degree of arteriolar hyalinosis, the hallmark of chronic CNI nephrotoxicity. Living at high altitude was markedly associated with a higher degree of arteriolar hyalinosis (p < 0.001). Hemoglobin levels confirmed the functional relevance of different arterial oxygenation among the groups (p = 0.01). Thus, patients living at high altitude seem to be more susceptible to the developemt of arteriolar hyalinosis after kidney transplantation. This article is protected by copyright. All rights reserved.