The Impact of the Banff v-Lesion on Rejection Classification and Outcomes: Insights from a Multicenter Study.

According to the Banff classification, intimal arteritis (v-lesion) contributes to diagnosing T cell-mediated rejection (TCMR) and antibody-mediated rejection (AMR), and signifies more severe TCMR.

This multicenter cohort study (N=5323 kidney transplants, N=16774 post-transplant biopsies) evaluated the impact of v-lesions (N=707 v-positive biopsies in N=534 transplants) on biopsy classification and outcomes.

The first v-positive biopsy of each transplant was categorized by additional Banff TCMR/(p)AMR-MVI criteria: 166 (31. 1%) isolated v, 87 (16. 3%) borderline changes with v, 66 (12. 4%) TCMR grade I (TCMR-I) with v, 148 (27. 7%) (p)AMR-MVI ((probable) AMR/DSAnegC4dneg MVI) with v, and 67 (12.

5%) TCMR-I + (p)AMR-MVI with v. Cases with additional TCMR/(p)AMR-MVI criteria were more often indication biopsies, had lower eGFR, and were more frequently HLA-DSA positive than isolated v.

While borderline changes with v had borderline higher 10-year graft failure rates than isolated v, TCMR-I, (p)AMR-MVI, and TCMR-I + (p)AMR-MVI with v were associated with significantly worse outcomes, although variably treated.

Matching N=534 v-positive cases to v-negative controls showed no significant impact of v-lesions on outcomes. These findings question the role of isolated v-lesions in rejection diagnosis and emphasize the greater prognostic value of additional TCMR and (p)AMR-MVI criteria.

Reconsideration of v-lesions in the Banff classification may be appropriate.