Schemas for Schemas for Histopathological Histopathological

Diagnosis of Rejection: Diagnosis of Rejection: Kidney Kidney

Kim Solez, M.D.

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Having fun creating order out of Having fun creating order out of chaos. Bird formations at edge of chaos. Bird formations at edge of Iguassu Falls!Iguassu Falls!

The Banff consensus The Banff consensus process is like that!process is like that!

The Banff consensus The Banff consensus process is like that!process is like that!

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Consensus Generation Online, Not Consensus Generation Online, Not Just Face to Face, Role of Protest.Just Face to Face, Role of Protest.

A good example of successful use A good example of successful use is the World Wide Web is the World Wide Web Consortium. “We reject kings, Consortium. “We reject kings, presidents, and voting. We presidents, and voting. We believe in rough consensus and believe in rough consensus and running code.” David Clark (MIT) running code.” David Clark (MIT)

““Consensus stops the majority Consensus stops the majority ruling the minority and is more ruling the minority and is more consistent with anarchist consistent with anarchist principles.” Anarchist FAQ. principles.” Anarchist FAQ.

ConsensUs: Computer-moderated ConsensUs: Computer-moderated Structured Discourse. Structured Discourse. http://faculty.washington.edu/gmhttp://faculty.washington.edu/gmobus/consensus.htmlobus/consensus.html

FacilitatePro – Online collab. tool.FacilitatePro – Online collab. tool.

A good example of successful use A good example of successful use is the World Wide Web is the World Wide Web Consortium. “We reject kings, Consortium. “We reject kings, presidents, and voting. We presidents, and voting. We believe in rough consensus and believe in rough consensus and running code.” David Clark (MIT) running code.” David Clark (MIT)

““Consensus stops the majority Consensus stops the majority ruling the minority and is more ruling the minority and is more consistent with anarchist consistent with anarchist principles.” Anarchist FAQ. principles.” Anarchist FAQ.

ConsensUs: Computer-moderated ConsensUs: Computer-moderated Structured Discourse. Structured Discourse. http://faculty.washington.edu/gmhttp://faculty.washington.edu/gmobus/consensus.htmlobus/consensus.html

FacilitatePro – Online collab. tool.FacilitatePro – Online collab. tool.

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Consensus Generation Online, Not Just Consensus Generation Online, Not Just Face to Face, Role of Protest, Alternate Face to Face, Role of Protest, Alternate Views.Views.

(Possible if Banff participants knew (Possible if Banff participants knew I researched this stuff as a I researched this stuff as a science, my facilitator role would science, my facilitator role would be less effective. So shhh! be less effective. So shhh! Mum’s the word!)Mum’s the word!)

(Possible if Banff participants knew (Possible if Banff participants knew I researched this stuff as a I researched this stuff as a science, my facilitator role would science, my facilitator role would be less effective. So shhh! be less effective. So shhh! Mum’s the word!)Mum’s the word!)

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History of the Banff Classification, History of the Banff Classification, Antecedents before 1991!Antecedents before 1991!

Hard to know where to begin! Always building unusual Hard to know where to begin! Always building unusual things, assisted, inspired by female friends - muses. Three-things, assisted, inspired by female friends - muses. Three-story shack in back yard, age 9.story shack in back yard, age 9.

Lorraine Racusen and I have worked together since she Lorraine Racusen and I have worked together since she joined me as a fellow in 1979.joined me as a fellow in 1979.

I left for Chairmanship in Pathology at University of Alberta I left for Chairmanship in Pathology at University of Alberta in Edmonton in 1987.in Edmonton in 1987.

Consensus generation experience: Future of Consensus generation experience: Future of Pathology/Laboratory Medicine in Canada Consortium, gave Pathology/Laboratory Medicine in Canada Consortium, gave Canadian laboratory physicians political clout.Canadian laboratory physicians political clout.

ISHLT Heart Classification published in 1990. Lorraine and I ISHLT Heart Classification published in 1990. Lorraine and I started working on Banff classification in early 1991.started working on Banff classification in early 1991.

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Lorraine Racusen in 1998 and Lorraine Racusen in 1998 and today.today.

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Banff Classification: Banff Classification: Milestones Milestones 1991 First Conference1991 First Conference

1993 First Kidney International publication1993 First Kidney International publication

1995 Integration with CADI 1995 Integration with CADI

1997 Integration with CCTT classification1997 Integration with CCTT classification

1999 Second KI paper. Clinical practice guidelines. 1999 Second KI paper. Clinical practice guidelines. Implantation biopsies, microwave.Implantation biopsies, microwave.

2001 Classification of antibody-mediated rejection2001 Classification of antibody-mediated rejection

Regulatory agencies participatingRegulatory agencies participating

2003 Genomics focus, ptc cell accumulation scoring2003 Genomics focus, ptc cell accumulation scoring

2005 Gene chip analysis. Elimination of CAN, 2005 Gene chip analysis. Elimination of CAN, identification of chronic antibody-mediated rejection.identification of chronic antibody-mediated rejection.

2007 First meeting far from a town called “Banff” – La 2007 First meeting far from a town called “Banff” – La Coruna, Spain.Coruna, Spain.

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artistartist citizencitizen

entrepreneurentrepreneur

BBC CreativityBBC Creativity

““connecting with connecting with

audiences”audiences”

We need to connect with We need to connect with audiences too! If we do audiences too! If we do it right we will be it right we will be changing the face of changing the face of medicine!medicine!

Someday the Someday the percutaneous biopsy will percutaneous biopsy will be replaced by some be replaced by some superior noninvasive superior noninvasive approach lacking the approach lacking the sampling error, sampling error, invasiveness, relative invasiveness, relative non-specificity of current non-specificity of current diagnostic assessment.diagnostic assessment.

““Wow, then we will be Wow, then we will be out of a job!”out of a job!”

vs.vs.

“Hey that will be really “Hey that will be really exciting to practice exciting to practice pathology like that!”pathology like that!”

The replacement of the The replacement of the invasive percutaneous invasive percutaneous biopsy approach by a biopsy approach by a noninvasive molecular noninvasive molecular biology/genomics biology/genomics approach has analogy in approach has analogy in major political change.major political change.

In the 80s one knew that In the 80s one knew that sometime apartheid in sometime apartheid in South Africa would end South Africa would end and the Berlin Wall would and the Berlin Wall would come down but would come down but would that happen in a day, a that happen in a day, a year, a decade, a year, a decade, a century?century?

Also have to be prepared Also have to be prepared for changes that could not for changes that could not be predicted, like the fall be predicted, like the fall of the Soviet Union. The of the Soviet Union. The unexpected change that unexpected change that alters everything!alters everything!

We now await similar We now await similar positive tumultuous positive tumultuous changes in the field of changes in the field of transplantation.transplantation.

And life will be better And life will be better after than before.after than before.

We need the right We need the right approach.approach.

"Possess the right "Possess the right thinking, in this you must thinking, in this you must never lapse."never lapse."

Splinter - the ninja Splinter - the ninja master/talking rat - Teenage master/talking rat - Teenage Mutant Ninja TurtleMutant Ninja Turtle movie (1990) movie (1990)

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Banff Conferences on Banff Conferences on Allograft Pathology Allograft Pathology 1991-?1991-?

Global consensus Global consensus generation while generation while maintaining intellectual maintaining intellectual freedom.freedom.

Like the mosh pit at a Like the mosh pit at a great rock concert. No great rock concert. No partner, the ultimate in partner, the ultimate in individuality, dangerous, individuality, dangerous, but when the but when the music is good music is good everyone dances in everyone dances in sync and life is sync and life is good. good.

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Two future phases in the Two future phases in the relationship between renal biopsies relationship between renal biopsies and management of the renal and management of the renal allograft recipientallograft recipient In the short term, the rigorous quantitation In the short term, the rigorous quantitation

and internationally-agreed-upon evaluation and internationally-agreed-upon evaluation of renal biopsies via the Banff of renal biopsies via the Banff Classification, which has proven itself Classification, which has proven itself quite useful in the early post-transplant quite useful in the early post-transplant period, will be extended to apply fully to period, will be extended to apply fully to late graft biopsieslate graft biopsies

In the long term,perhaps years or decades In the long term,perhaps years or decades away, the processes of acute and chronic away, the processes of acute and chronic rejection will be so well understood rejection will be so well understood mechanistically that a test for specific mechanistically that a test for specific markers in blood or urine will completely markers in blood or urine will completely replace the percutaneous biopsy as a means replace the percutaneous biopsy as a means of diagnosing these conditionsof diagnosing these conditions

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Other Causes of Kidney Other Causes of Kidney Scarring – Why “CAN” does us Scarring – Why “CAN” does us a disservice!a disservice! Hypertensive vascular disease.Hypertensive vascular disease.

Chronic calcineurin inhibitor toxocity.Chronic calcineurin inhibitor toxocity.

Obstruction.Obstruction.

Chronic polyoma virus infection.Chronic polyoma virus infection.

Donor origin vascular disease.Donor origin vascular disease.

Chronic bacterial infection.Chronic bacterial infection.

Recurrent or de novo glomerular diseaseRecurrent or de novo glomerular disease

Recurrent or de novo vascular disease.Recurrent or de novo vascular disease.

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Chronic scarring in Banff Chronic scarring in Banff Classification – CAN gone.Classification – CAN gone. 5. Interstitial fibrosis and tubular atrophy 5. Interstitial fibrosis and tubular atrophy

(nephron loss), cause unknown. (Every attempt (nephron loss), cause unknown. (Every attempt should be made to assign cases to known should be made to assign cases to known etiologies from other categories 2, 4, and etiologies from other categories 2, 4, and 6.".... With interstitial fibrosis and tubular 6.".... With interstitial fibrosis and tubular atrophy" Assignment to this cause-unknown atrophy" Assignment to this cause-unknown category is a last resort.)category is a last resort.)

Grade I Mild interstitial fibrosis and tubular Grade I Mild interstitial fibrosis and tubular atrophy (atrophy ( 25% of cortical area 25% of cortical area

Grade II Moderate interstitial fibrosis and Grade II Moderate interstitial fibrosis and tubular atrophy (26-50% of cortical area)tubular atrophy (26-50% of cortical area)

Grade III Severe interstitial fibrosis and Grade III Severe interstitial fibrosis and tubular atrophy/ loss (tubular atrophy/ loss ( 50% of cortical area) 50% of cortical area)

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Antibody Mediated Rejection Antibody Mediated Rejection in Banff Classificationin Banff Classification 2. Antibody-mediated rejection Rejection due, at 2. Antibody-mediated rejection Rejection due, at

least in part, to documented anti-donor antibody least in part, to documented anti-donor antibody (‘suspicious for’ if antibody not demonstrated)(‘suspicious for’ if antibody not demonstrated)

Acute Acute

ATN-like – C4d +, minimal inflammation ATN-like – C4d +, minimal inflammation

Capillary- margination and/or thromboses, C4d + Capillary- margination and/or thromboses, C4d +

Arterial – v3, C4d + Arterial – v3, C4d +

Chronic activeChronic active

PTC basement membrane multilayering. chronic PTC basement membrane multilayering. chronic transplant glomerulopathy (cg 1-3, mm 1-3), C4d transplant glomerulopathy (cg 1-3, mm 1-3), C4d ++

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T Cell Mediated RejectionT Cell Mediated Rejection

4. Acute/active cellular rejection may coincide 4. Acute/active cellular rejection may coincide with categories 2 and 5 Type (Grade) with categories 2 and 5 Type (Grade) Histopathological findings IA Cases with Histopathological findings IA Cases with significant interstitial infiltration (>25% of significant interstitial infiltration (>25% of parenchyma affected) and foci of moderate parenchyma affected) and foci of moderate tubulitis (>4 mononuclear cells/tubular cross tubulitis (>4 mononuclear cells/tubular cross section or group of 10 tubular cells) IB Cases section or group of 10 tubular cells) IB Cases with significant interstitial infiltration with significant interstitial infiltration (>25% of parenchyma affected) and foci of (>25% of parenchyma affected) and foci of severe tubulitis (>10 mononuclear cells/tubular severe tubulitis (>10 mononuclear cells/tubular cross-section or group of 10 tubular cells) IIA cross-section or group of 10 tubular cells) IIA Cases with mild to moderate intimal arteritis Cases with mild to moderate intimal arteritis (v1) IIB Cases with severe intimal arteritis (v1) IIB Cases with severe intimal arteritis comprising >25% of the luminal area (v2) III comprising >25% of the luminal area (v2) III Cases with ‘transmural’ arteritis and/or Cases with ‘transmural’ arteritis and/or arterial fibrinoid change and necrosis of arterial fibrinoid change and necrosis of medial smooth muscle cells (v3)medial smooth muscle cells (v3)

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More than half of transplant More than half of transplant biopsies in 2005 do not show biopsies in 2005 do not show rejection!rejection!

Calcineurin inhibitor toxicity Calcineurin inhibitor toxicity most common entity. most common entity.

Scoring/classification system Scoring/classification system must deal with all entities, not must deal with all entities, not just rejection!just rejection!

New onset hyaline arteriolar New onset hyaline arteriolar thickening (ah) a sign of thickening (ah) a sign of calcineurin inhibitor toxicity.calcineurin inhibitor toxicity.

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Non- Circumferential vs. Circumferential hyalinosisNon- Circumferential vs. Circumferential hyalinosisNon- Circumferential vs. Circumferential hyalinosisNon- Circumferential vs. Circumferential hyalinosis

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Quantitative Criteria for Arteriolar Quantitative Criteria for Arteriolar Hyaline Thickening – Proposed new Hyaline Thickening – Proposed new scoring - Mihatschscoring - Mihatsch

0 = No PAS-positive hyaline thickening0 = No PAS-positive hyaline thickening

1 = PAS-positive hyaline thickening1 = PAS-positive hyaline thickening present in only one arteriole, no present in only one arteriole, no circular involvement circular involvement

2 = PAS-positive hyaline thickening 2 = PAS-positive hyaline thickening present in more than one arteriole, but present in more than one arteriole, but no circular involvementno circular involvement

3 = PAS-positive hyaline thickening 3 = PAS-positive hyaline thickening with with circular involvement, independent of the circular involvement, independent of the number of arterioles involved number of arterioles involved

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Quantitative Criteria for Arteriolar Quantitative Criteria for Arteriolar Hyaline Thickening – Study of Sis et Hyaline Thickening – Study of Sis et al. (Banff ’05)al. (Banff ’05)

The severity of ah scored by both criteria, was The severity of ah scored by both criteria, was significantly correlated with serum creatinine at biopsy significantly correlated with serum creatinine at biopsy (p<0.05). Using Banff criteria, the mean rate of pairwise (p<0.05). Using Banff criteria, the mean rate of pairwise agreement was 57.8% with an overall kappa value of 0.39. agreement was 57.8% with an overall kappa value of 0.39. With the newly proposed criteria, the mean rate of With the newly proposed criteria, the mean rate of pairwise agreement was 70% and the overall kappa value was pairwise agreement was 70% and the overall kappa value was 0.51. The mean interslide variation rates using Banff 0.51. The mean interslide variation rates using Banff criteria and the new criterion were 30.7% and 36.7%, criteria and the new criterion were 30.7% and 36.7%, respectively.respectively.

Conclusion:Conclusion: While Banff and the recently proposed criteria While Banff and the recently proposed criteria for ah scoring resulted in fair to moderate interobserver for ah scoring resulted in fair to moderate interobserver agreement, the new criterion seems to be more objective agreement, the new criterion seems to be more objective and results in better interobserver reproducibility. There and results in better interobserver reproducibility. There is a substantial variation in the distribution and is a substantial variation in the distribution and severity of arteriolar lesions in an individual biopsy, severity of arteriolar lesions in an individual biopsy, therefore, evaluation of more than one section is crucial therefore, evaluation of more than one section is crucial to determine the severity of arteriolar damage more to determine the severity of arteriolar damage more accurately.accurately.

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Specimen Adequacy – (Banff Specimen Adequacy – (Banff ’97, ‘05) Minimum ’97, ‘05) Minimum Sampling,proceduresSampling,procedures

Unsatisfactory – No glomeruli or Unsatisfactory – No glomeruli or arteriesarteries

Marginal – 7 glomeruli with an arteryMarginal – 7 glomeruli with an artery

Adequate – 10 or more glomeruli with at Adequate – 10 or more glomeruli with at least two arteriesleast two arteries

Minimum Sampling: 7 slides – 3 H&E, 3 Minimum Sampling: 7 slides – 3 H&E, 3 PAS or silver stains, and 1 trichromePAS or silver stains, and 1 trichrome

Must do C4d!Must do C4d!

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DNA MicroarraysDNA Microarrays

Transcription of many thousands of Transcription of many thousands of genes can be measured on one tiny chipgenes can be measured on one tiny chip

Define mechanisms of rejection and Define mechanisms of rejection and other complications that arise in other complications that arise in transplant kidneystransplant kidneys

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Affymetrix Affymetrix GeneChip® GeneChip® probe array. probe array. Image courtesy of Image courtesy of Affymetrix.Affymetrix.

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DNA synthesis(replication)

RNA synthesis(transcription)

protein synthesis(translation)

DNA

RNA

Protein

amino acids

From DNA to Protein

microarrays

real-time RT-PCR

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CTL genes in human kidney biopsies CTL genes in human kidney biopsies normalized vs well functioning normalized vs well functioning transplantstransplants

Tx1

Tx8

Tx4

Tx5

NR1

NR2

NR3

Tx7

AR2

AR3

AR4

AR6

AR1

AR7

NR5

AR5

Tx2

Tx6

Tx10

Tx9

Tx3

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Current ResearchCurrent Research

Microarray analysis of both human & Microarray analysis of both human & mouse kidney transplants with rejection mouse kidney transplants with rejection and other complicationsand other complications

Correlate with Clinical data & Banff Correlate with Clinical data & Banff lesionslesions

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Human and Mouse similar genes and similar development

The Cell 2002.

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OutlookOutlook

Discover patterns in mouse and human kidney txDiscover patterns in mouse and human kidney tx

define molecular basis of Banff lesions define molecular basis of Banff lesions

develop an array-based Banff classificationdevelop an array-based Banff classification

identify blood patterns correlating with biopsy patterns identify blood patterns correlating with biopsy patterns

Validate patterns in large scale studyValidate patterns in large scale study

USA, Canada centers c.f. Matas-Halloran consortiumUSA, Canada centers c.f. Matas-Halloran consortium

Develop new gold standardDevelop new gold standard

consensus in Banff processconsensus in Banff process

recognition by FDA: endpointsrecognition by FDA: endpoints

Develop commercial opportunities: IP, products, servicesDevelop commercial opportunities: IP, products, services

ExtendExtend

Other organ and tissue transplantsOther organ and tissue transplants

Autoimmune and infectious diseases e.g. hepatitis cAutoimmune and infectious diseases e.g. hepatitis c

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Become part of the ongoing Become part of the ongoing discussionsdiscussions

Contact: Kim.Solez@UAlberta.ca or Contact: Kim.Solez@UAlberta.ca or Michele.Hales@UAlberta.caMichele.Hales@UAlberta.ca

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Future Banff Meetings:Future Banff Meetings:

2007 - La Coruna, Spain2007 - La Coruna, Spain

2009 - Whistler, British Columbia, 2009 - Whistler, British Columbia, CanadaCanada

2011 - Paris, France2011 - Paris, France

2013 - Banff, Alberta, Canada2013 - Banff, Alberta, Canada

2015 - Stockholm, Sweden2015 - Stockholm, Sweden