Does the Banff rejection activity index predict outcome in patients with early acute cellular rejection following liver transplantation?

Abstract

The Banff schema incorporates a semiquantitative scoring system for grading of acute cellular rejection (ACR) of the liver allograft. The Banff rejection activity index (RAI) comprises 3 components scored from 0 to 3: venous endothelial inflammation (E); bile duct damage (B); and portal inflammation (P); the scores are combined to an overall score (the RAI). The purpose of this research was to determine the prognostic value of the Banff RAI score in predicting the response to increased immunosuppression and the long-term outcome of the graft. A retrospective study was done of patients undergoing primary liver transplantation between January 2000 and October 2004 with tacrolimus-based immunosuppression; 495 patients were included, 231 had histologically-confirmed ACR, 193 responded to 1 cycle of high-dose steroids. There was no correlation between the total RAI score and response to steroids, resistant rejection, development of chronic rejection, or graft survival. The E score was related to patient survival, a lower score being associated with a worse outcome (P ϭ 0.048). In multivariable analysis, serum bilirubin, serum aspartate aminotransferase, and E score were significant predictors of death (P ϭ 0.012). In univariable analysis, B score and bilirubin were significantly related to "resistant rejection" (P ϭ 0.018 and 0.002, respectively), but only bilirubin was significant in multivariable analysis (logistic regression). In conclusion, although the Banff RAI score is a useful marker of the severity of rejection, neither the total RAI score nor any of the individual components correlated with response to steroids or graft survival. Acute cellular rejection (ACR) remains a common problem following liver transplantation (LT) affecting up to 60% of patients receiving tacrolimus.

Review on immunosuppression in liver transplantation

“…It also may not precisely predict the response to medical management [110] . High dose iv corticosteroid is the first line of treatment for moderate to severe ACR in most centers.…”

The dynamic changes of Th17/Treg cytokines in rat liver transplant rejection and tolerance

“…The histological findings of HE staining were graded according to the Banff scheme [13]. The rejection activity index (RAI) was calculated from the three individual scores [14] (venous endothelial inflammation, bile duct damage, and portal inflammation).…”

Infiltrative (sinusoidal) and hepatitic patterns of injury in acute cellular rejection in liver allograft with clinical implications

“…There is the potential that adding these features will improve the current poor Banff scoring performance for predicting steroid response or graft survival. 4 The second concept, not addressed by our findings but clearly a relevant one is the role, if any, of alloantibodies in these infiltrative and hACR patterns. Although none of the patients in this cohort had been transplanted across ABO groups, and all were primary (first) transplants, unfortunately none had donor-specific antibody data available to enable us to address this question.…”

“…3 The Banff scale, however, has not been independently validated and its individual components have not been shown to predict graft survival or response to steroids. 4 Nevertheless, the morphologic criteria described for acute cellular rejection by this system are widely accepted parameters even when its numerical weightings are not applied. Pathologists have recognized additional patterns of injury in acute cellular rejection after liver transplantation, not incorporated in the Banff criteria.…”