The 2024 Banff meeting was from September 16-20 in Paris. We solicited the below input from the international transplant community to guide in-person discussions.
Note: The full meeting program and registration information can be found here: https://site.pheedloop.com/event/2024BanffPITOR/home)*
*some final changes to session and presentation titles might occur
Join the conversation onTCMR, AMR and mixed rejection by commenting on:
What are the most important knowledge gaps and/or unmet clinical needs?
What questions would you ask the moderators and speakers?
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Yes we need a process for mixed as is it common late.
i like separating the components in some arrangement like:
the dominant clinico-pathological diagnosis integrating all data (inc DSA) as the first line
e.g. AMR and starting with the immunologcial diagnosis if that is the primary expanatory abnormality - as that is clinician will needs to respond to.
2. the secondary diagnosis on the next line (e.g mixed with TCMR for example, or with CA-TCMR if you have C AMR) if that is of less pathological importance. We need separating them out to allows for targeted treatment. (e.g we can treat TCMR easily whereas chronic AMR is harder)
3. Other backgroung features commonly:
a) nephron loss as IFTA % as this estimates salvageable kidney and is informative for treatment decision and determins in part the therapeutic response (along with patient factors which will be considered by the clinician.
b) CNI nephrotoxicity etc.
Regarding the “new phenotypes” pAMR and C4d neg DSA neg MVI, which are probably “milder” disease, how do we make sure patients are not treated too aggressively as would be appropriate for acute AMR? How do we incorporate these phenotypes into an activity and chronicity index?
The wording of how we as pathologists sign out mixed AMR and TCMR is problematic. Do we call it “mixed” and list what we think are the most important patterns (eg endothelialitis, C4d positivity, transplant glomerulopathy), or separate out the AMR and TCMR components as two diagnoses, and what do we do with the vascular lesions that can be seen in both AMR and TCMR? What are the most important features in mixed rejection?
Thanks for putting together a great session! I hope more can be done for ambiguous arterial lesions (arteritis, chronic allograft arteriopathy, &/or ischemic arteriopathy) & other ambiguous lesions. The same goes for transplant glomerulopathy, which can have multiple causes. How much are T cell-mediated rejection, antibody-mediated rejection, & other etiologies contributing to these lesions. We have clinicopathologic clues, but there are still puzzling cases. What more can we do to tease out lesions that send mixed signals? I look forward to a great session!
With the advent of the new induction/maintenance protocols and more efficient patient monitoring, the histological features of allorejection are not as black and white clearcut TCMR vs ABMR anymore and the percentage of mild and overlapping rejections, which could not be clearly classified as one or the other is increasing in pathology practice. However, the nephrologists still treat based on the Banff categories and expect a definitive classification from the pathologist . Are there any other techniques/methods/tests by which the histological features could be further refined so that the patient receives the appropriate treatment? So much of the molecular hype seems to be focused on replacing pathology but could transcriptomics (or omics in general) help classify such overlapping rejection cases? Looking forward to attending the exciting sessions and visiting Paris!
Demystification of tubulointerstitial nephritis in transplantation. How can we define of a T cell response in situ is an alloimmune response? Can we determine clinicopathological archetypes for TIN as well?
I am wondering, does the ordinal degree scoring of Banff lesions truly correlated with severity of one or the other rejection type? In mixed rejection, it would be important to know how much of TCMR and how much of ABMR a patient has. Maybe the molecular assessments can quantify that better?