Introduction: Eighth Banff Conference on Allograft Pathology - Edmonton, AB Kim Solez, M.D. and Lorraine C. Racusen

Slide 2 Making Banff into a verb! “Banff it” 2005 most important meeting yet. “Kicking the CAN” - Coming to grips with the morphologic counterparts of chronic graft failure - getting away from the nonspecificity of “CAN”. “Kicking the CAN” - Coming to grips with the morphologic counterparts of chronic graft failure - getting away from the nonspecificity of “CAN”. “Banff on a chip” - The emerging role of gene chip microarray results. “Banff on a chip” - The emerging role of gene chip microarray results. “Rules for the masses” - Revisiting clinical practice guidelines, C4d, new lesion scores. “Rules for the masses” - Revisiting clinical practice guidelines, C4d, new lesion scores.

Slide 3 Edmonton, where the Banff Meetings have been organized from since 1991! Largest metropolitan center between Toronto and Vancouver, and Canada's fifth-largest city. Largest metropolitan center between Toronto and Vancouver, and Canada's fifth-largest city. 2,263.7 hours of sunlight in the average year - more than any other major city in Canada. 2,263.7 hours of sunlight in the average year - more than any other major city in Canada. Average of 17 hours of daylight per day in June. Average of 17 hours of daylight per day in June. Edmonton’s River Valley is the largest stretch of urban parkland in North America with 7400 hectares; this vast parkland is approximately 12 times larger than Central Park in New York City Edmonton’s River Valley is the largest stretch of urban parkland in North America with 7400 hectares; this vast parkland is approximately 12 times larger than Central Park in New York City. Largest metropolitan center between Toronto and Vancouver, and Canada's fifth-largest city. Largest metropolitan center between Toronto and Vancouver, and Canada's fifth-largest city. 2,263.7 hours of sunlight in the average year - more than any other major city in Canada. 2,263.7 hours of sunlight in the average year - more than any other major city in Canada. Average of 17 hours of daylight per day in June. Average of 17 hours of daylight per day in June. Edmonton’s River Valley is the largest stretch of urban parkland in North America with 7400 hectares; this vast parkland is approximately 12 times larger than Central Park in New York City Edmonton’s River Valley is the largest stretch of urban parkland in North America with 7400 hectares; this vast parkland is approximately 12 times larger than Central Park in New York City.

Slide 4 The Banff Schema was first developed by a group of pathologists, nephrologists, and transplant surgeons at a meeting in Banff Canada August 2-4, The Banff Schema was first developed by a group of pathologists, nephrologists, and transplant surgeons at a meeting in Banff Canada August 2-4, The Banff Schema was first developed by a group of pathologists, nephrologists, and transplant surgeons at a meeting in Banff Canada August 2-4, The Banff Schema was first developed by a group of pathologists, nephrologists, and transplant surgeons at a meeting in Banff Canada August 2-4, It has continued to evolve through meetings every two years and has become the worldwide standard for interpretation of transplant biopsies. It has continued to evolve through meetings every two years and has become the worldwide standard for interpretation of transplant biopsies.

Slide 5 Banff Classification: Milestones 1991 First Conference 1991 First Conference 1993 First Kidney International publication 1993 First Kidney International publication 1995 Integration with CADI 1995 Integration with CADI 1997 Integration with CCTT classification 1997 Integration with CCTT classification 1999 Second KI paper. Clinical practice guidelines. Implantation biopsies, microwave Second KI paper. Clinical practice guidelines. Implantation biopsies, microwave Classification of antibody-mediated rejection 2001 Classification of antibody-mediated rejection Regulatory agencies participating Regulatory agencies participating 2003 Genomics focus, ptc cell accumulation scoring, macrophages Genomics focus, ptc cell accumulation scoring, macrophages.

Slide 6 Banff Classification - Subjects in Edmonton meeting July 15-21, 2005 Updates on Schemas for Diagnosis of Rejection Updates on Schemas for Diagnosis of Rejection Transcriptome Gene Chip Diagnoses Transcriptome Gene Chip Diagnoses Emerging Technologies Emerging Technologies Antibody-mediated rejection/C4d Antibody-mediated rejection/C4d Special Populations Special Populations Revisiting Clinical Practice Guidelines Revisiting Clinical Practice Guidelines Histologic hallmarks of sclerosing rejection: Strategies to establish diagnoses other than CAN. Histologic hallmarks of sclerosing rejection: Strategies to establish diagnoses other than CAN. Heart, lung, pancreas, and liver sessions in addition. Heart, lung, pancreas, and liver sessions in addition.

Slide 7 Much important work being presented in poster session! Poster session Monday, July 18th 5:30 - 7:30 5:30 - 7:30 Poster Viewing Session Poster Viewing Session Wine & Cheese Event Wine & Cheese Event Posters can be put up during the breaks or 7- 8 AM tomorrow or Monday Posters can be put up during the breaks or 7- 8 AM tomorrow or Monday

Slide 8 More than half of transplant biopsies in 2005 do not show rejection! Calcineurin inhibitor toxicity most common entity. Scoring/classification system must deal with all entities, not just rejection! New onset hyaline arteriolar thickening (ah) a sign of calcineurin inhibitor toxicity.

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Slide 10 Non- Circumferential vs. Circumferential hyalinosis

Slide 11 Quantitative Criteria for Arteriolar Hyaline Thickening – Current scoring. 0 = No PAS-positive hyaline thickening 1 = Mild-to-moderate PAS-positive hyaline thickening in at least one arteriole 2 = Moderate-to-severe PAS-positive hyaline thickening in more than one arteriole 3 = Severe PAS-positive hyaline thickening in many arterioles

Slide 12 Quantitative Criteria for Arteriolar Hyaline Thickening – Proposed new scoring - Mihatsch 0 = No PAS-positive hyaline thickening 1 = PAS-positive hyaline thickening present in only one arteriole, no circular involvement 2 = PAS-positive hyaline thickening present in more than one arteriole, but no circular involvement 3 = PAS-positive hyaline thickening with circular involvement, independent of the number of arterioles involved

Slide 13 Quantitative Criteria for Arteriolar Hyaline Thickening – Study of Sis et al. (Banff ’05) The severity of ah scored by both criteria, was significantly correlated with serum creatinine at biopsy (p<0.05). Using Banff criteria, the mean rate of pairwise agreement was 57.8% with an overall kappa value of With the newly proposed criteria, the mean rate of pairwise agreement was 70% and the overall kappa value was The mean interslide variation rates using Banff criteria and the new criterion were 30.7% and 36.7%, respectively. The severity of ah scored by both criteria, was significantly correlated with serum creatinine at biopsy (p<0.05). Using Banff criteria, the mean rate of pairwise agreement was 57.8% with an overall kappa value of With the newly proposed criteria, the mean rate of pairwise agreement was 70% and the overall kappa value was The mean interslide variation rates using Banff criteria and the new criterion were 30.7% and 36.7%, respectively. Conclusion: While Banff and the recently proposed criteria for ah scoring resulted in fair to moderate interobserver agreement, the new criterion seems to be more objective and results in better interobserver reproducibility. There is a substantial variation in the distribution and severity of arteriolar lesions in an individual biopsy, therefore, evaluation of more than one section is crucial to determine the severity of arteriolar damage more accurately. Conclusion: While Banff and the recently proposed criteria for ah scoring resulted in fair to moderate interobserver agreement, the new criterion seems to be more objective and results in better interobserver reproducibility. There is a substantial variation in the distribution and severity of arteriolar lesions in an individual biopsy, therefore, evaluation of more than one section is crucial to determine the severity of arteriolar damage more accurately.

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Slide 15 Intimal elastosis found to correlated with antibody mediated rejection! Sis, Hunter et al. Intimal elastosis - the deposition of elastic fibers in intima - significant association with class II antibodies in our study may suggest that antibody mediated injury could be one of the mechanisms leading to arterial injury and subsequent formation of neo-intima rich in elastic fibers. Intimal elastosis - the deposition of elastic fibers in intima - significant association with class II antibodies in our study may suggest that antibody mediated injury could be one of the mechanisms leading to arterial injury and subsequent formation of neo-intima rich in elastic fibers. 173 posttransplant biopsies from 127 patients with available anti-HLA Ab analysis Jan to March posttransplant biopsies from 127 patients with available anti-HLA Ab analysis Jan to March 2004

Slide 16 Moving from semiquantitative scoring to quantitative scoring by morphometry! Despite all the praise we have received for the Banff scoring system, a truly quantitative system would obviously be better if practical, so we are only half way there! Despite all the praise we have received for the Banff scoring system, a truly quantitative system would obviously be better if practical, so we are only half way there! Howie AJ: The Problems with BANFF, Transplantation 73:1383, 2002 “…other approaches should be tried such as morphometry” Howie AJ: The Problems with BANFF, Transplantation 73:1383, 2002 “…other approaches should be tried such as morphometry” Financially and technically impractical for most centers right now, but possibly doable in the near future. Financially and technically impractical for most centers right now, but possibly doable in the near future. Banff classification is based on semiquantitative assessment. Quantitative assessment would ultimately be better, just as the molecular biology/genomics alternative would be. But they must be made practical! Banff classification is based on semiquantitative assessment. Quantitative assessment would ultimately be better, just as the molecular biology/genomics alternative would be. But they must be made practical!

Slide 17 New Developments in Morphometry - Birk et al. (2005 Banff meeting) Used hue saturation intensity (HSI) image analysis software to quantify renal allograft interstitial fibrosis in pediatric protocol biopsies, significant correlation with Banff ci score and with decreased GFR and other clinical parameters. Used hue saturation intensity (HSI) image analysis software to quantify renal allograft interstitial fibrosis in pediatric protocol biopsies, significant correlation with Banff ci score and with decreased GFR and other clinical parameters.

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Slide 19 Clinical practice guidelines, new lesion scoring etc. Revisiting 1999 guidelines. Revisiting 1999 guidelines. Methods review for C4d as a marker for antibody mediated rejection. Methods review for C4d as a marker for antibody mediated rejection. Peritubular capillary cell accumulation scoring. Peritubular capillary cell accumulation scoring.

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Slide 21 Polys in peritubular capillaries in antibody-mediated rejection.

Slide Agreed upon clinical practice guidelines that need buy-in generally Implantation biopsies Implantation biopsies Rapid paraffin (microwave) processing for rapid reading rather than frozen sections Rapid paraffin (microwave) processing for rapid reading rather than frozen sections Routine (“protocol”) biopsies Routine (“protocol”) biopsies H&E, PAS (+/o silver), and trichrome or Sirius red stains H&E, PAS (+/o silver), and trichrome or Sirius red stains

Schedule of the Meeting Saturday, 16 July :00 - 8:20 Welcome, Opening Remarks - Kim Solez and Lorraine Racusen Plenary session 8:20 - 9:20 Keynote Address: Future directions in organ replacement. - Jeffrey Platt Transcriptome Gene Chip Moderator: Philip F. Halloran 9:20-11:50 12:00 - 1:00Lunch (Wedgwood Room)Lunch (Empire Terrace) PMEmpire Ballroom 12:00 - 1:00Lunch (Wedgwood Room)Lunch (Empire Terrace) PMEmpire Ballroom 1:00 - 1:30Experimental heart transplantation. - Thomas Mueller Emerging Technologies Moderator: Philip F. Halloran 1:30-4:30 Saturday, 16 July :00 - 8:20 Welcome, Opening Remarks - Kim Solez and Lorraine Racusen Plenary session 8:20 - 9:20 Keynote Address: Future directions in organ replacement. - Jeffrey Platt Transcriptome Gene Chip Moderator: Philip F. Halloran 9:20-11:50 12:00 - 1:00Lunch (Wedgwood Room)Lunch (Empire Terrace) PMEmpire Ballroom 12:00 - 1:00Lunch (Wedgwood Room)Lunch (Empire Terrace) PMEmpire Ballroom 1:00 - 1:30Experimental heart transplantation. - Thomas Mueller Emerging Technologies Moderator: Philip F. Halloran 1:30-4:30