1. The Banff Classification: Slide Seminar Kim Solez, M.D.

2. Slide 2 The Banff Schema was first developed by a group of pathologists, nephrologists, and transplant surgeons at a meeting in Banff Canada August 2-4, 1991. The Banff Schema was first developed by a group of pathologists, nephrologists, and transplant surgeons at a meeting in Banff Canada August 2-4, 1991. The Banff Schema was first developed by a group of pathologists, nephrologists, and transplant surgeons at a meeting in Banff Canada August 2-4, 1991. The Banff Schema was first developed by a group of pathologists, nephrologists, and transplant surgeons at a meeting in Banff Canada August 2-4, 1991. 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.

3. Slide 3 Banff Classification: Milestones 1991 First Conference 1991 First Conference 1993 First Kidney International publication 1993 First Kidney International publication 1995 Integration with CADI - identical scoring 1995 Integration with CADI - identical scoring 1997 Integration with CCTT classification 1997 Integration with CCTT classification 1999 Second KI paper. Clinical practice guidelines. Implantation biopsies, microwave. 1999 Second KI paper. Clinical practice guidelines. Implantation biopsies, microwave. 2001 Classification of antibody-mediated rejection 2001 Classification of antibody-mediated rejection Regulatory agencies participating Regulatory agencies participating

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8. Slide 8 Quantitative Criteria for Arteriolar Hyaline Thickening 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

9. Slide 9 Changes not considered to be due to rejection Post-transplant lymphoproliferative disorder Post-transplant lymphoproliferative disorder Non-specific changes Non-specific changes focal interstitial inflammation without tubulitis: Nodular infiltrates, perivascular infiltrates focal interstitial inflammation without tubulitis: Nodular infiltrates, perivascular infiltrates vascular changes: endothelial reactive changes, vacuolization, venulitis. vascular changes: endothelial reactive changes, vacuolization, venulitis. Acute Tubular Injury Acute Tubular Injury Acute Interstitial Nephritis Acute Interstitial Nephritis Cyclosporine-associated changes, acute or chronic Cyclosporine-associated changes, acute or chronic Subcapsular Injury Subcapsular Injury Pre-transplant Acute Endothelial Injury Pre-transplant Acute Endothelial Injury Papillary Necrosis Papillary Necrosis De novo Glomerulonephritis De novo Glomerulonephritis Recurrent Disease Recurrent Disease Pre-existing Disease Pre-existing Disease Other-viral infection (CMV), obstruction and reflux Other-viral infection (CMV), obstruction and reflux

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11. Slide 11 Specimen Adequacy – (Banff ’97) Minimum Sampling Unsatisfactory – No glomeruli or arteries Unsatisfactory – No glomeruli or arteries Marginal – 7 glomeruli with an artery Marginal – 7 glomeruli with an artery Adequate – 10 or more glomeruli with at least two arteries Adequate – 10 or more glomeruli with at least two arteries Minimum Sampling: 7 slides – 3 H&E, 3 PAS or silver stains, and 1 trichrome Minimum Sampling: 7 slides – 3 H&E, 3 PAS or silver stains, and 1 trichrome

12. Slide 12 Standardization of tx biopsy interpretation. Banff Classification Classification begun at 1991 Classification begun at 1991 Banff meeting has become the worldwide standard Banff meeting has become the worldwide standard Consensus process has now extended to all solid organs Consensus process has now extended to all solid organs Meetings continue every two years. Next meeting in Edmonton in summer of 2005 Meetings continue every two years. Next meeting in Edmonton in summer of 2005 Future meetings planned every two years through 2009 Future meetings planned every two years through 2009 Standardization principles now being extended from biopsy reporting to tissue typing, imaging, all the other elements in transplant care Standardization principles now being extended from biopsy reporting to tissue typing, imaging, all the other elements in transplant care

13. Slide 13 Standardization of tx biopsy interpretation. Banff Classification Lesion quantitation Lesion quantitation Reproducibility and clinical validation studies Reproducibility and clinical validation studies Involvement of pathologists, clinicians, surgeons, scientists, registries, and regulatory agencies in consensus generation Involvement of pathologists, clinicians, surgeons, scientists, registries, and regulatory agencies in consensus generation Meetings have large amount of unstructured time for deliberation and consensus generation Meetings have large amount of unstructured time for deliberation and consensus generation Most content online at: http://cnserver0.nkf.med.ualberta.ca/Banff Most content online at: http://cnserver0.nkf.med.ualberta.ca/Banff http://cnserver0.nkf.med.ualberta.ca/Banff Linked from http://www.cybernephrology.org Linked from http://www.cybernephrology.org

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17. Slide 17 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

18. Slide 18 Perioperative (implantation) Biopsy Core vs wedge Core vs wedge Adequacy of sample Adequacy of sample Preimplantation vs. postimplantation Preimplantation vs. postimplantation Consensus: Consensus: Perioperative biopsy (? core, ? wedge) is sufficiently safe to be recommended for any reasonable defined objective Perioperative biopsy (? core, ? wedge) is sufficiently safe to be recommended for any reasonable defined objective STANDARD OF CARE!

19. Slide 19 Protocol (routine) biopsies Early and intermediate post-transplant protocol biopsies Early and intermediate post-transplant protocol biopsies Consensus: Consensus: Generally done under ultrasound guidance Generally done under ultrasound guidance Have very low morbidity Have very low morbidity Safe enough to be requested of consenting patients for research purposes when the objectives are clearly formulated and stated Safe enough to be requested of consenting patients for research purposes when the objectives are clearly formulated and stated STANDARD OF SCIENCE!

20. Slide 20 Future Banff Meetings: 2005 - Edmonton, Alberta, Canada 2005 - Edmonton, Alberta, Canada 2007 - Edinburgh, Scotland 2007 - Edinburgh, Scotland 2009 - Banff, Alberta, Canada 2009 - Banff, Alberta, Canada

21. Slide 21Close Banff ’97 Classification is the new universal classification of kidney transplant pathology Banff ’97 Classification is the new universal classification of kidney transplant pathology Future improvements involve participation in Banff meetings via physical presence or contributions via Internet Future improvements involve participation in Banff meetings via physical presence or contributions via Internet

22. Slide 22 Subscribe to free Nephrol Email group: Become part of the ongoing discussions To subscribe: send an E-mail message to majordomo@ualberta.ca with the message “subscribe Nephrol” (or Nephrol-digest) Or contact Kim.Solez@UAlberta.ca or Michele.Hales@UAlberta.ca