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.
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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 the great effort of performing the post-meeting survey and the very helpful 2024 Report, which addresses a lot of recurrent questions that one is confronted with in daily routine.
There is some very small points I was wondering about:
-Figure 1
Diagnosis of chronic-active TCMR:
In the 2019 classification it was specifically stated that chronic-active tubulointerstital rejection is defined by i-IFTA2 or 3 AND ti2 or 3 with t2 OR tIFTA2 for Grade IA and with t3 OR t-IFTA3 for Grade IB. In the susequent publications, also the present one, it appears that t-IFTA2 or 3 without t2 or t3 would not be sufficient for the diagnosis. What was the reason to change this back? To me it appeared a sensible change of the definition.
List of concomitant causes of tubulointerstitial inflammation:
- Neutrophilic tubulitis is also very helpful in the diagsnosis of ascending infection.
- (IF/IHC/EM) instead of (IF/EM) might be considered
-Table S3
In the table of comments it says repeatedly that „Biopsy-based transcripts diagnostics could be considered if available“. In cases with findings below threshold for a rejection diagnosis this is surely very helpful. However, is there actually enough evidence to recommend this proceeding in cases, in which rejection cannot be differentiated from eg. TMA of other cause or GN. Can AMR or TCMR be differentiated from TMA or GN using one of the currently used transcript tools? Sorry, if I am not up to date with the literature.