Lung Rejection Study Group

Revision of the 1996 Working Formulation for the Standardization of Nomenclature in the Diagnosis of Lung Rejection

Susan Stewart, FRCPath; Michael C. Fishbein, MD; Gregory I. Snell, MD; Gerald J. Berry, MD; Annette Boehler, MD; Margaret M. Burke, FRCPath; Alan Glanville, MD; F. Kate Gould, FRCPath; Cynthia Magro, MD; Charles C. Marboe, MD; Keith D. McNeil, FRACP; Elaine F. Reed, PhD; Nancy L. Reinsmoen, PhD; John P. Scott, MD; Sean M. Studer, MD; Henry D. Tazelaar, MD; John L. Wallwork, FRCS; Glen Westall, MD; Martin R. Zamora, MD; Adriana Zeevi, PhD; and Samuel A. Yousem, MD


IIn 1990, an international grading scheme for the grading of pulmonary allograft rejection was adopted by the International Society for Heart and Lung Transplantation (ISHLT) and was modified in 1995 by an expanded group of pathologists. The original and revised classifications have served the lung transplant community well, facilitating communication between transplant centers with regard to both patient management and research. In 2006, under the direction of the ISHLT, a multi-disciplinary review of the biopsy grading system was undertaken to update the scheme, address inconsistencies of use, and consider the current knowledge of antibody-mediated rejection in the lung. This article summarizes the revised consensus classification of lung allograft rejection. In brief, acute rejection is based on perivascular and interstitial mononuclear infiltrates, Grade A0 (none), Grade A1 (minimal), Grade A2 (mild), Grade A3 (moderate) and Grade A4 (severe), as previously. The revised (R) categories of small airways inflammation, lymphocytic bronchiolitis, are as follows: Grade B0 (none), Grade B1R (low grade, 1996, B1 and B2), Grade B2R (high grade, 1996, B3 and B4) and BX (ungradeable). Chronic rejection, obliterative bronchiolitis (Grade C), is described as present (C1) or absent (C0), without reference to presence of inflammatory activity. Chronic vascular rejection is unchanged as Grade D. Recommendations are made for the evaluation of antibody-mediated rejection, recognizing that this is a controversial entity in the lung, less well developed and understood than in other solid-organ grafts, and with no consensus reached on diagnostic features. Differential diagnoses of acute rejection, airway inflammation and chronic rejection are described and technical considerations revisited. This consensus revision of the working formulation was approved by the ISHLT board of directors in April 2007. Copyright © 2007 by the International Society for Heart and Lung Transplantation.

The Journal of Heart and Lung Transplantation, December 2007, 1229 - 1242.

From: From the Papworth Everard Pathology Department, Papworth Hospital, Cambridge, UK.
Submitted: Submitted October 29, 2007; revised October 30, 2007; accepted October 31, 2007.
Copyright: Copyright © 2007 by the International Society for Heart and Lung Transplantation. 1053-2498/07/$-see front matter. doi: 10.1016/j.healun.2007.10.017.
Reprint Requests: Reprint requests: Susan Stewart, FRCPath, Papworth Everard Pathology Department, Papworth Hospital, Cambridge CB3 8RE, UK. Telephone: 44-1480-364-304. Fax: 44-1480-364-777. E-mail:

Please mail comments, corrections or suggestions to the TPIS administration at the UPMC.

Last Modified: Thu Oct 11 7:37:00 EDT 2016


Please give your feedback about this page here:


If you have more questions, you can always email TPIS Administration.