The Banff 2024 Kidney Meeting Report: Rejection as a Spectrum of Phenotypes and Focus on Non-Rejection Glomerular Disease
M. Naesens and C. Roufosse et al.
Read the full manuscript on SSRN
Abstract
The XVII-th Banff Meeting for Allograft Pathology was held in Paris, France, from 16th-20th September 2024, hosted by the Paris Institute for Transplantation & Organ Regeneration (PITOR). The Banff 2024 meeting resulted in no changes to the Banff Kidney Classification. Important outputs of the meeting were a re-affirmation of the clinical usefulness of the clinical reasoning framework and flowchart for cases with microvascular inflammation/AMR introduced at the Banff 2022 meeting, and introduction of a similar flowchart for tubulointerstitial inflammation and intimal arteritis (v lesion). The meeting highlighted the complexity of the immunological processes (alloimmune and other) that lead to allograft inflammation, and the need to strengthen the Banff system for differential diagnostic reasoning. This includes digital and molecular tools that have potential to help transform the Classification into a probabilistic tool reflective of the underlying immunological processes. Consensus-based guidance is put in place for cases with incomplete/mixed phenotypes, that acknowledges the limits of our understanding, and a proposal for potential future implementation of activity and chronicity scores was discussed. Finally, consensus was reached on guidelines for reporting of glomerular disease in the post-transplant setting.
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Clinical feasibility and utility of the classification
Areas of improvement for clarity and reduction of ambiguity
Inaccuracies and inconsistency
Evidence and knowledge gaps
The comment period will be open until August 31, 2025. All comments will be reviewed and considered by the Banff meeting report author groups prior to finalizing the manuscripts and submission for formal peer review.
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Thank you for publishing the Banff 2024 Meeting Report—I had been looking forward to its release. The flowcharts in Figures 1 and 2 are extremely helpful for understanding the complexities of rejection diagnostics.
Two minor suggestions for Figure 2
All three branches that follow “v lesions present” run in parallel. To make that parallel structure more intuitive, it may help to add a direct arrow from the parent node to the central box (“Tubulo-interstitial inflammation at or above t1/i1 …”) just as you have arrows to the left- and right-hand boxes.
The lower-left box is labeled “Mixed rejection (AMR/MVI + TCMR grade II)”. Because biopsies with a v3 score also follow this branch, “TCMR grade II or III” would be more accurate.
Question on interpretation
The same lower-left box classifies AMR/MVI cases with a v lesion as “Mixed rejection (AMR + TCMR)”. Yet intimal arteritis (v lesions) can arise within the pathophysiology of AMR itself. Might that box therefore encompass both pure AMR and Mixed rejection, depending on the broader context? I would appreciate the Working Group’s perspective on how the v lesion is weighed when deciding whether TCMR is truly concomitant.
Thank you again for making this valuable report available. I look forward to further discussion and future developments.
Sincerely,
Takahiro Tsuji