Standardization of renal allograft biopsy interpretation is necessary to guide therapy. This manuscript describes milestones of the Banff classification for renal allograft pathology developed by an international investigators conference. From small beginnings in 1991, the Banff working classification of renal allograft pathology has grown to be a major force for setting standards in renal transplant pathology. The meeting, classification, and consensus process have a unique history. Semiquantitative scorings of key lesions, such as tubulitis, interstitial inflammation, capillaritis, arteritis, and others, make a central core of the Banff scheme. The Banff classification proposed many new concepts related to pathogenesis of rejection. There are many important issues, including T-lymphocyte related rejaction, antibody-mediated rejection (ABMR), chronic active rejection, and C4d negative antibody-mediated rejection. ABMR is associated with heterogeneous phenotypes even within the same type of transplant. The willingness of the Banff process to continually adapt in response to new research and to improve potential weaknesses led to the implementation of six working groups in the following areas: isolated v-lesion, fibrosis scoring, glomerular lesions, molecular pathology, polyomavirus nephropathy, and quality assurance. Furthermore, compelling molecular research data led to the discussion of incorporation of omics technologies and the discovery of new tissue markers with the goal of soon combining histopathology and molecular parameters within the Banff working classification.
Endomyocardial biopsy is widely adopted as an important examination process for the diagnosis of allograft rejection after heart transplantation. The initial standardized grading system was instituted by the International Society of Heart and Lung Transplantation (ISHLT) in 1990 and was used for over 10 years. Some discrepancies between the pathologic findings and clinical conditions were indicated according to the development of new knowledge and therapy for rejection in the Banff and ISHLT meetings, and the revised grading system was demonstrated in 2004. In this revision, the grading of cellular rejection was largely modified to more standardized diagnose everywhere, and the simple grading for antibody mediated rejection (AMR) started being used. The treatment for AMR has been the major topic in Banff and ISHLT meetings, and the current pathologic grading of AMR was published in 2013. More data will be accumulated soon in relation to this topic.
In 2012, the Banff Working Group on Liver Allograft Pathology published a review article on how biopsy findings should be used to adjust immunosuppressive therapy, including weaning of immunosuppression, evaluation of operational tolerance and antibody-mediated rejection (AMR). The liver sessions of the Banff Conference held in 2013 focused primarily on diagnostic criteria of AMR. The next consensus document is in preparation for liver allograft AMR, including histologic findings, interpretation of C4d staining, and correlation with serologic testing. The relationship between chronic AMR and possible effects on liver allograft fibrosis is uncertain and in need of further study.
In the 12th Banff meeting held in Brazil from August 19 to 23, 2013, data from multiple clinicopathological studies as well as molecular pathology concerning pathogenesis of antibody mediated rejection (ABMR) were presented, and the revised criteria for ABMR was rigorously discussed. Other advances include the proposed refinement of criteria for C4d positivity; transplant glomerulopathy (TG), in which the cg0 score was defined as no feature of TG in the ultrastructural study; and transplant glomerulitis. In this report, the overview of these topics will be presented. A summary report of ongoing Banff working groups on isolated v-lesion and polyoma virus nephropathy is presented. The future scope of newly set working groups covering T-cell mediated rejection is also discussed.
Pancreas transplantation has become a standard therapy for type 1 diabetic patients. Although a short-term graft survival has been improved, a long-term graft survival is still far from ideal. Recently, a needle core biopsy of the pancreatic graft is safely indicated for the diagnosis of rejection by the patients who underwent pancreas transplantation. Banff classification for the biopsy specimen of the kidney graft was applied for the pancreas since the 2007 Banff conference, and the Banff classification for rejection has been proposed in 2011. This classification includes acute cell-mediated rejection (Grades I-III), antibodv-mediated rejection (donor-specific antibody), morphological evidence of tissue injury, C4d positivity, chronic allograft arteriopathy., chronic allograft rejection/graft sclerosis (Stages l-lll), islet pathology, recurrence of autoimmune DM, and other histological diagnoses. Recently, antibodv-mediated rejection (AMR), especially chronic AMR resulting in the pancreatic fibrosis, has been noticed and focused on at Banff conferences.
Lung transplantation is the ultimate treatment for irreversible end-stage pulmonary diseases. The histopathologic standardized grading scheme of cellular rejection for pulmonary allograft has been developed by the International Society for Heart and Lung Transplantation (ISHLT) and is now broadly accepted. The acute antibody-mediated rejection (AMR) has been highlighted at the Banff meeting in recent years, and increased attention has also been paid to it in regard to pulmonary allograft. However, AMR in lung transplantation has been debatable, and histopathologic and immunophenotypic criteria were adopted as not yet being established. In thise paper we present the recommendation of clinicopathologic findings possibly associated with AMR in lung allograft.
【Background/Aim】Adherence to immunosuppressive medication among liver transplant recipients is crucial for patient outcome. The parents are greatly involved in the management of immunosuppressants for children, which is different from that for adults. We performed a questionnaire survey to assess the factors related to adherence toward immunosuppressive medication among pediatric patients; the questionnaire sought responses to "I nursed it" and "how I should intervene?" 【Patients and methods】From January 1994 to December 2010, nineteen live-donor liver transplants (recipients younger than 15) were performed in our institute. 【Results】One patient was excluded because the patient is immunosuppression-free. The questionnaire response rate was 88.9% (16 of 18 responses generated). The median age of the transplant recipients and questionnaire survey participants was 5.5 years and 11 years. Self-adherence to immunosuppressive medication was observed in 6 recipients (38%), and parent-monitored adherence was observed in 10 (62%) recipients. The frequency of nonadherence was observed as follows: no instances of missed dose; 4 patients rarely missed dose; 7 patients occasionally missed dose; 2 patients intermittently missed dose; 3 patients. The most common reason for nonadherence was "forgot." 【Conclusion】The importance of immunosuppressive medication should be continually informed to pediatric recipients and their parents to create the awareness to adherence. About the time to begin self-control of an oral medicine, recipients and their parents are in the state of groping and considered to be worth showing an indicator by intervention of nursing.
【Objective】Different characteristics are found between adult and pediatric recipients of liver transplantation. However, a detailed nationwide database of pediatric liver transplantations has not been fully elucidated in Japan. Therefore it is necessary to accumulate such a nationwide registry of data on pediatric liver transplants. The primary objective of the database is to characterize the trends in indications, outcomes, and developments in pediatric liver transplantations in Japan. 【Methods】In 2013, the on-line registration system was opened at several Japanese pediatric liver transplantation centers in Japan. This registry is designed to collect data online, and the subjects will be donors and recipients aged less than 18 years at the time of transplantation. The composition of this registry is classified into 3 categories, and 436 items. 【Results】We added some evaluation items of growth and development to LITRE-J (Liver Transplantation REgistry in Japan). We will collect prospective data on children receiving liver transplantations at the pediatric liver transplant centers in Japan and accumulate comprehensive data on pre-and posttransplant outcomes of pediatric liver transplantations. 【Conclusion】That the data accumulated by this registration system are expected to serve as basic histories and statistics data for the evaluation and development of pediatric liver transplantations in Japan, such as improvements in results by standardized medical treatment through decisions of the guidelines.
We report on our experience in kidney transplantations (KTs) in our center during the past 10 years (2002-2012). Forty KTs were performed for 39 recipients: 33 donors were live; 6 were nonheart beating; and 1 was brain-dead. The median age of donors was 43 (minimum 20-maximum 67). Donation procedures for the live donors had been open nephrectomy until 2009; they have been hand-assisted laparoscopic nephrectomy since 2010. Median recipient age was 9.5 (min. 2-max. 30), and the indications of KT included congenital anomalies of kidney and urinary tracts in 11, nephronophthisis in 6, focal segmental glomerulosclerosis in 5, and so on. ABO-incompatible KTs were performed on 8 recipients. Recipient procedures were performed by retroperitoneal approach, except for 8 recipients who had a laparotomy with vascular anastomoses to the abdominal aorta and inferior vena cava. Ureteral anastomoses were performed by extravesicular ureteral implantations except for 2 recipients. Twenty-two recipients (55%) developed infectious complications after KTs, which included cytomegalovirus infection, Ebstein-Barr infection, urinary tract infection, and 12 (30%) developed acute rejection. Surgical complications included urinary leakage from the anastomosis, vesicoureteral reflux to the graft, and intestinal obstruction. Four grafts were lost, including one patient death with a functioning graft. Nine-year graft survival was 88.5%.