Dean D E, Kamath S, Peddi V R, Schroeder T J, First M R, Cavallo T
Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Ohio 45267-0529, USA.
Transplantation. 1999 Sep 15;68(5):642-5. doi: 10.1097/00007890-199909150-00008.
We sought to determine whether diagnoses established through the Banff schema for evaluation of renal allograft pathology have implications for clinical management, compared with diagnoses established using descriptive terminology.
All patients included in this study had mild to severe allograft rejection diagnosed, and, as part of a therapeutic protocol, they received OKT3 as primary anti-rejection therapy. We conducted a retrospective review of their renal allograft biopsy specimens and reclassified them, using the Banff schema, without knowledge of clinical information, laboratory data, or previous biopsy interpretation. Although there is no strict correspondence between descriptive diagnostic terminology and the criteria used in the Banff schema, for the purpose of comparisons, the following approximation was used: mild and mild to moderate rejection=Banff borderline and Banff grade 1, moderate and moderate to severe rejection=Banff grades 2A and 2B, and severe rejection=Banff grade 3. The diagnosis was considered concordant when the diagnosis by descriptive terminology and Banff grading were within the adopted approximation.
Of 96 biopsies specimens with mild to severe allograft rejection, 10 were insufficient for diagnosis, and three had changes of chronic allograft rejection. Of the remaining 83 biopsy specimens, 34 (41%) were concordant in interpretation of rejection grades, whereas 49 (59%) were discrepant. The greatest degree of concordance was in grades 2A (66.7%, 18 of 27) and 2B (64.7% 11 of 17), and the lowest was in the borderline category (11.8%, 2 of 17). The greatest degree of discrepancy was in normal and grade 3 (100%, 3 of 3 and 2 of 2, respectively), and the lowest was in grade 2A (33.3%, 9 of 27). Although primary anti-rejection therapy with OKT3 resulted in a high reversal rate of rejection (98%), there were 5 deaths, 12 graft loses, six episodes of serious infections, and three malignancies in this group of patients during a mean follow-up period of approximately 38 months.
Because patients with borderline changes and grades 1 and 2A rejection may be treated differently from patients with higher grades (2B and 3), the use of the Banff schema may allow for better adjustment of immunosuppressive therapy in response to specific grades of acute allograft rejection and may result in decreased complications of immunosuppressive therapy.
我们试图确定，与使用描述性术语做出的诊断相比，通过用于评估肾移植病理的班夫分类法做出的诊断是否对临床管理有影响。
本研究纳入的所有患者均被诊断为轻度至重度移植肾排斥反应，并且作为治疗方案的一部分，他们接受OKT3作为主要抗排斥治疗。我们对他们的移植肾活检标本进行了回顾性审查，并在不了解临床信息、实验室数据或先前活检解读的情况下，使用班夫分类法对其进行重新分类。虽然描述性诊断术语与班夫分类法中使用的标准之间没有严格对应关系，但为了进行比较，采用了以下近似对应：轻度和轻度至中度排斥反应=班夫临界和班夫1级，中度和中度至重度排斥反应=班夫2A级和2B级，重度排斥反应=班夫3级。当描述性术语诊断和班夫分级在采用的近似范围内时，诊断被认为是一致的。
在96例有轻度至重度移植肾排斥反应的活检标本中，10例标本诊断不足，3例有慢性移植肾排斥反应的改变。在其余83例活检标本中，34例（41%）在排斥反应分级的解读上是一致的，而49例（59%）不一致。一致性程度最高的是2A级（66.7%，27例中的18例）和2B级（64.7%，17例中的11例），最低的是临界类别（11.8%，17例中的2例）。差异程度最大的是正常和3级（分别为100%，3例中的3例和2例中的2例），最低的是2A级（33.3%，27例中的9例）。虽然使用OKT3进行主要抗排斥治疗导致排斥反应的逆转率很高（98%），但在这组患者平均约38个月的随访期间，有5例死亡、12例移植肾丢失、6次严重感染发作和三例恶性肿瘤。
由于临界改变以及1级和2A级排斥反应的患者可能与更高级别（2B级和3级）的患者治疗方式不同，使用班夫分类法可能有助于根据急性移植肾排斥反应的特定级别更好地调整免疫抑制治疗，并可能减少免疫抑制治疗的并发症。
