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Untitled
Allograft Kidney Biopsy Template
(2 H & E, 1 PAS, 1 MST, 1 Trichrome)
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| | 1.1 Number of glomeruli | ( ) |
| | 1.2 Number globally sclerotic | ( ) |
| | 1.3 Segmental sclerosis | ( )Yes | ( ) No |
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| 2. Glomerulitis (g) | ( )0 ( )1 ( )2 ( )3 |
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| 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 |
| 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 | ( ) |
| 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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This page copyright University of Pittsburgh 2001
Last Modified: Thu Jun 18 10:14:08 EDT 2009
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