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Allograft Kidney Biopsy Template


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1. Glomerulosclerosis
1.1 Number of glomeruli( )
1.2 Number globally sclerotic( )
1.3 Segmental sclerosis( )Yes( ) No ( ) N/A
1.4 Management biopsy( )Yes( ) No ( ) N/A
2. Glomerulitis (g)( )0 ( )1 ( )2 ( )3 ( ) N/A
3. Ti: Total interstitial inflammation (i)( )0 ( )1 ( )2 ( )3 ( ) N/A
3a. i-Banff = % inflammation with non-scarred areas as numerator and denominator ( )0 ( )1 ( )2 ( )3 ( )N/A
3b. i-IFTA = % inflammation with scarred areas as numerator and denominator ( )0 ( )1 ( )2 ( )3 ( )N/A
4. Intimal arteritis (v)( )0 ( )1 ( )2 ( )3 ( )Not evaluable
5. t-Banff: tubulitis (t)( )0 ( )1 ( )2 ( )3 ( )N/A
6. Arteriolar hyalin (ah)( )0 ( )1 ( )2 ( )3 ( ) Not evaluable
6a. Nodular form( )Yes( ) No
7. Chronic glomerular change (cg)( )0 ( )1 ( )2 ( )3 ( )N/A
7b. Mesangial matrix increase (mm)( )0 ( )1 ( )2 ( )3 ( )N/A
8. Interstitial fibrosis on trichrome stain (ci)( )0 ( )1 ( )2 ( )3 ( )N/A
9. Tubular atrophy (ct)( )0 ( )1 ( )2 ( )3 ( )N/A
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: Acute/active antibody mediated rejection
( )KDABD: Diagnostic: Needs (i) histologic injury, (ii) evidence of antibody-endothelial interaction, and (iii) donor specific antibody (g>0 and/or peritubular capillary>0, v>0) (C4d2/3 by IF and/or C4d>0 by IPEX, and or g+ptc ≥ 2 for C4d negative ABMR)(in presence of TCMR/borderline change/infection g must be at least 1 to use g+ptc sum criterion)
( )KDAB I: ATN-like, C4d +, minimal inflammation
( )KDAB II: Capillary margination, glomerulitis, and/or thromboses, C4d +
( )KDAB III: Arterial v3, C4d +
( ) C4d substituted by g+ptc ≥2 and g ≥1 (check mark if this criterion is used as substitute for C4d)
( ) DSA substituted by C4d (check mark if this criterion is being used as substitute for DSA)
( )KDChAB-A: Chronic active antibody-mediated rejection: Needs chronic tissue injury, evidence of antibody-endothelial interaction, and donor specific antibody (cg>0 and/or new onset CV &/or electron microscopy) (C4d2/3 by IF, and/or C4d>0 by IPEX, and/or g+ptc ≥2 if C4d negative)
( ) KDChAB: Chronic antibody-mediated rejection: Term used when there is absence of evidence of current/recent antibody-endothelial interaction, but chronic tissue injury and DSA are present.
( ) KDC4Dst: C4d staining without evidence of rejection: Needs all three of the following criteria: (i) g=0, v=0, cg=0, TMA=0, AKI=0, (ii) (C4d2/3 by IF and/or C4d>0 by IPEX, and (iii) absence of borderline change or TCMR.
( ) Borderline change (i1-3, t0-1) or (i0-1, t1-3), (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)
( ) KDCa-TCMR:chronic active TCMR (grade 1A, 1B, or II)
( ) KDCa-TCMR IA: Ti>1, i-IFTA>1, t-IFTA = 2 exclude severely atrophic tubules & other causes i-IFTA
( ) KDCa-TCMR IB: Ti>1, i-IFTA>1, t-IFTA = 3 excluding severely atrophic tubules & other causes i-IFTA
( ) KDCa-TCMR IIA: Chronic allograft arteriopathy (arterial intimal fibrosis with mononuclear cell inflammation in fibrosis and formation of neointima)
( ) Interstitial fibrosis/tubular atrophy (IFTA)/Chronic allograft nephropathy (specify cg,ci,ct,cv grades):
( )KDCR1a: Mild, without cg and specific vascular changes (disruption of elastica and/or inflammatory cells in the fibrotic intima)
( )KDCR1b: Mild, with cg and/or specific vascular changes (disruption of elastica and/or inflammatory cells in the fibrotic intima)
( )KDCR2a: Moderate, without cg and specific vascular changes (disruption of elastica and/or inflammatory cells in the fibrotic intima)
( )KDCR2b: Moderate, with cg and/or specific vascular changes (disruption of elastica and/or inflammatory cells in the fibrotic intima)
( )KDCR3a: Severe, without cg and specific vascular changes (disruption of elastica and/or inflammatory cells in the fibrotic intima)
( )KDCR3b: Severe, with cg and/or specific vascular changes (disruption of elastica and/or inflammatory cells in the fibrotic intima)
( ) 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)
13. PAS and MST glomerular basement membrane changes ( ) Yes ( ) No ( )N/A
14. C4d
a. Glomerular: minimal ( ) focal ( ) diffuse ( ) negative ( ) not done ( )
b. Peritubular capillaries: minimal ( ) focal ( ) diffuse ( ) negative ( ) not done ( )
c. Arteries: minimal ( ) focal ( ) diffuse ( ) negative ( ) not done ( )
15. Plasma cells >15/hpf over 5 fields ( ) Yes ( ) No ( ) N/A
16. PTCis (<10%, >10% with 3-4, 5-10, >10/capillary) ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) N/A


8/23/99, 3/13/00, 7/11/00, 11/23/01, 7/8/03, 01/29/04 (C4d), 11/05/04, 10/04/06, 04/12/07 (C4d Method), 9/7/07 (PTC), 9/15/09 (AAMR, CAMR, IFTA), 12/30/13 (C4d negative) 1/28/14 (chronic tissue) 10/10/18 (i-IFTA)
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Last Modified: 10/28/18 10:42 PM EDT

 

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