Banff ABMR Workgroup calls out deficiencies in Banff 17 recommendations.
In this article, the Banff Antibody-mediated injury workgroup surveyed an international cohort of nephrologists, surgeons, and renal pathologists to determine how antibody-mediated rejection (ABMR) is diagnosed in clinical practice. Crucially, and despite being a central testing requirement for the diagnosis of ABMR, the survey revealed that in most cases (>60%) reported by the respondents, DSA information was not available at the time of diagnosis. Several reasons were proposed to explain the absence or delay in DSA results. These included:
Furthermore, the survey revealed that around of third of respondents felt that Banff ’17 did not adequately account for the histologic changes considered “suspicious for ABMR” when observed in the absence of DSA or positive C4d staining. Additionally, many of those also surveyed report taking into account other factors not included in the Banff classification, such as the testing timepoint post-transplant when making their diagnosis.
Another key finding is that even when DSA is absent, and the biopsy shows features indicative of ABMR, roughly 20% of those surveyed routinely order additional non-HLA testing or molecular transcript analysis, with >80% of respondents citing a belief that these tests will not change patient management.
The authors put forward a compelling argument that the tools needed for optimal use of the Banff ABMR classification system are not being utilized or are not always readily available, although they observe that using these tools is vital in achieving an accurate ABMR diagnosis. Without this, it becomes difficult to study factors such as treatment efficacy or the underlying disease mechanisms.
The survey also calls for greater efforts from researchers, histocompatibility experts, and pathologists to increase the understanding of the roles of HLA and non-HLA antibodies in kidney transplantation. The study concludes that, at the very least, the focus should be placed on expanding the accessibility of DSA test results. From improving the level of available donor HLA typing (specifically the inclusion of DQ and DP typing) to developing processes to ensure serum availability for future DSA testing, the authors highlight many areas of improvement that would positively impact the accuracy of ABMR diagnosis in the future.
By: Dave Lowe
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