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Allograft Kidney Biopsy Template
(2 H & E, 1 PAS, 1 MST, 1 Trichrome)
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1. Glomerulosclerosis
1.1 Number of glomeruli( )
1.2 Number globally sclerotic( )
1.3 Segmental sclerosis( )Yes( ) No
2. Glomerulitis (g)( )0 ( )1 ( )2 ( )3
3. Interstitial inflammation (i)( )0 ( )1 ( )2 ( )3
(check if present)( )Neutrophils( ) Eosinophils
4. Intimal arteritis (v)( )0 ( )1 ( )2 ( )3 ( )Not evaluable
5. Tubulitis (t)( )0 ( )1 ( )2 ( )3
6. Arteriolar hyalin (ah)( )0 ( )1 ( )2 ( )3
Nodular form( )Yes( ) No
7. Chronic glomerular change (cg)( )0 ( )1 ( )2 ( )3
7b. Mesangial matrix increase (mm)( )0 ( )1 ( )2 ( )3
8. Interstitial fibrosis (ci)( )0 ( )1 ( )2 ( )3
9. Tubular atrophy (ct)( )0 ( )1 ( )2 ( )3
10. Vascular intimal sclerosis (cv)( )0 ( )1 ( )2 ( )3 ( ) not evaluable
10b. Number of arteries with internal elastic lamina( )
11. Other findings:
12. Diagnostic categories (check as many categories as appropriate)
( ) KDARO: Normal
( ) KDAB: Antibody mediated rejection
( ) KDARB: Borderline change (i0-2, t0-2, v0)
( ) Acute rejection (specify g,i,t,v grades):
( ) KDAR1A: Banff Type 1A (i1-3, t2, v0)
( ) KDAR1B: Banff Type 1B (i2-3, t3, v0)
( ) KDAR2A: Banff Type 2A (i1-3, t0-3, v1)
( ) KDAR2B: Banff Type 2B (i1-3, t0-3, v2)
( ) KDAR3: Banff Type 3 (i1-3, t0-3, v3)
( ) Chronic allograft nephropathy (specify cg,ci,ct,cv grades):
( ) KDCR1A: Mild, without specific changes suggesting chronic rejection
( ) KDCR1B: Mild, with specific changes suggesting chronic rejection
( ) KDCR2A: Moderate, without specific changes suggesting chronic rejection
( ) KDCR2B: Moderate, with specific changes suggesting chronic rejection
( ) KDCR3A: Severe, without specific changes suggesting chronic rejection
( ) KDCR3B: Severe, with specific changes suggesting chronic rejection
( ) KDDR: Tubular and/or myocyte vacuolization c/w drug-associated changes
( ) KDAT: Acute tubular necrosis
( ) KDDO: Donor disease
( ) Recurrent disease (specify)
( ) Subcapsular injury ( ) Pyelonephritis ( ) Polyoma virus
( ) CMV ( ) PTLD
( ) Obstruction ( ) Reflux
( ) Vascular thrombosis (specify)
( ) Miscellaneous (specify)
( ) PAS, Trichrome, MST GBM changes ( )Yes ( )No

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Last Modified: Thu Jun 18 10:14:08 EDT 2009