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Am J Transplant. 2019 Jan;19(1):123-131. doi: 10.1111/ajt.14979. Epub 2018 Jul 19.

Banff survey on antibody-mediated rejection clinical practices in kidney transplantation: Diagnostic misinterpretation has potential therapeutic implications.

Author information

1
William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA.
2
Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Center, Montreal, QC, Canada.
3
Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.
4
Department of Nephrology, University Hospitals Leuven, Leuven, Belgium.
5
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA.
6
Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
7
Department of Transplantation Surgery, Yale University School of Medicine, New Haven, CT, USA.
8
Department of Medicine and Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada.
9
Department of Pathology, Erasmus Medical Center, Rotterdam, Netherlands.
10
Medstar Georgetown Transplant Institute, Washington, DC, USA.
11
Department of Cardiac, Thoracic and Vascular Sciences, Transplant Immunology Unit, Padua University Hospital, Padua, Italy.
12
Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, NY, USA.
13
Institut d'Incestigacions Biomèdiques August Pi i Sunyer and Kidney Transplant Unit, Hospital Clínic, Barcelona, Spain.
14
Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivmedizin, Charité Universitätsmedizin Berlin, Berlin, Germany.
15
Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington, KY, USA.
16
Department of Surgery, University of California, San Francisco School of Medicine, San Francisco, CA, USA.
17
Department of Internal Medicine and Transplantation, Erasmus University Medical Center, Rotterdam, Netherlands.
18
Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
19
Division of Nephrology/Transplant Nephrology, Johns Hopkins University, Baltimore, MD, USA.

Abstract

The aim of this study was to determine how the Banff antibody-mediated rejection (ABMR) classification for kidney transplantation is interpreted in practice and affects therapy. The Banff Antibody-Mediated Injury Workgroup electronically surveyed clinicians and pathologists worldwide regarding diagnosis and treatment for 6 case-based scenarios. The participants' (95 clinicians and 72 renal pathologists) assigned diagnoses were compared to the Banff intended diagnoses (reference standard). The assigned diagnoses and reference standard differed by 26.1% (SD 28.1%) for pathologists and 34.5% (SD 23.3%) for clinicians. The greatest discordance between the reference standard and clinicians' diagnosis was when histologic features of ABMR were present but donor-specific antibody was undetected (49.4% [43/87]). For pathologists, the greatest discordance was in the case of acute/active ABMR C4d staining negative in a positive crossmatch transplant recipient (33.8% [23/68]). Treatment approaches were heterogeneous but linked to the assigned diagnosis. When acute/active ABMR was diagnosed by the clinician, treatment was recommended 95.3% (SD 18.4%) of the time vs only 77.7% (SD 39.2%) of the time when chronic active ABMR was diagnosed (P < .0001). In conclusion, the Banff ABMR classification is vulnerable to misinterpretation, which potentially has patient management implications. Continued efforts are needed to improve the understanding and standardized application of ABMR classification in the transplant community.

KEYWORDS:

classification systems: Banff classification; clinical decision making; clinical research/practice; kidney transplantation/nephrology; rejection: antibody-mediated (ABMR)

PMID:
29935060
PMCID:
PMC6309659
[Available on 2020-01-01]
DOI:
10.1111/ajt.14979

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