Diagnostic criteria for kidney transplant rejection: A call to action

摘要

The study by Carmen Lefaucheur and colleagues (Jan 26, p 313) shows the consequences of misdiagnosis of antibody-mediated vascular rejection. 45% of patients with antibody-mediated vascular rejection were misdiagnosed as T-cell-mediated vascular rejection, did not recover after anti-T-cell treatment, and most of these patients lost their transplanted kidneys. We think these diagnostic errors can be explained by: inadequate criteria in the international Banff classification; and lack of reliable biomarkers for antibody-mediated rejection. The Banff classification allows a diagnosis of antibody-mediated vascular rejection only if there is severe arteritis concomitant with donor-specific antibodies, and positive C4d staining in capillaries. The Banff criteria classify cases with less severe arteritis with an a-priori diagnosis of T-cell-mediated rejection. Moreover, C4d capillary staining, used as a biomarker for antibody-mediated rejection, has a poor sensitivity.3 In Lefaucheur and colleagues' study, 82% of antibody-mediated vascular rejections had mild-or-moderate arteritis and 44% were C4d-negative.