The evolution of the Banff classification schema for diagnosing renal allograft rejection and its implications for clinicians

Bhowmik, D; Dinda, AK; Pj, Mahanta; Agarwal, SK

doi:10.4103/0971-4065.62086

Cited by 42 publications

(28 citation statements)

References 19 publications

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“…The gradings are as follows: grade I, moderate to severe mononuclear cell interstitial infiltrate and moderate tubulitis; grade II, severe tubulitis and/or intimal arteritis; and grade III, transmural arteritis. 6 Incidences of ARs after a transplant are included in this appraisal; however, the treatment for AR is outside the scope of this appraisal.…”

Section: Survival Acute Rejection and Graft Loss After Transplantationmentioning

confidence: 99%

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Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model

Jones-Hughes

Snowsill

Haasova

et al. 2016

Health Technol Assess

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BackgroundEnd-stage renal disease is a long-term irreversible decline in kidney function requiring renal replacement therapy: kidney transplantation, haemodialysis or peritoneal dialysis. The preferred option is kidney transplantation, followed by immunosuppressive therapy (induction and maintenance therapy) to reduce the risk of kidney rejection and prolong graft survival.ObjectivesTo review and update the evidence for the clinical effectiveness and cost-effectiveness of basiliximab (BAS) (Simulect®, Novartis Pharmaceuticals UK Ltd) and rabbit anti-human thymocyte immunoglobulin (rATG) (Thymoglobulin®, Sanofi) as induction therapy, and immediate-release tacrolimus (TAC) (Adoport®, Sandoz; Capexion®, Mylan; Modigraf®, Astellas Pharma; Perixis®, Accord Healthcare; Prograf®, Astellas Pharma; Tacni®, Teva; Vivadex®, Dexcel Pharma), prolonged-release tacrolimus (Advagraf®Astellas Pharma), belatacept (BEL) (Nulojix®, Bristol-Myers Squibb), mycophenolate mofetil (MMF) (Arzip®, Zentiva; CellCept®, Roche Products; Myfenax®, Teva), mycophenolate sodium (MPS) (Myfortic®, Novartis Pharmaceuticals UK Ltd), sirolimus (SRL) (Rapamune®, Pfizer) and everolimus (EVL) (Certican®, Novartis) as maintenance therapy in adult renal transplantation.MethodsClinical effectiveness searches were conducted until 18 November 2014 in MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (via Wiley Online Library) and Web of Science (via ISI), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment (The Cochrane Library via Wiley Online Library) and Health Management Information Consortium (via Ovid). Cost-effectiveness searches were conducted until 18 November 2014 using a costs or economic literature search filter in MEDLINE (via Ovid), EMBASE (via Ovid), NHS Economic Evaluation Database (via Wiley Online Library), Web of Science (via ISI), Health Economic Evaluations Database (via Wiley Online Library) and the American Economic Association’s electronic bibliography (via EconLit, EBSCOhost). Included studies were selected according to predefined methods and criteria. A random-effects model was used to analyse clinical effectiveness data (odds ratios for binary data and mean differences for continuous data). Network meta-analyses were undertaken within a Bayesian framework. A new discrete time–state transition economic model (semi-Markov) was developed, with acute rejection, graft function (GRF) and new-onset diabetes mellitus used to extrapolate graft survival. Recipients were assumed to be in one of three health states: functioning graft, graft loss or death.ResultsEighty-nine randomised controlled trials (RCTs), of variable quality, were included. For induction therapy, no treatment appeared more effective than another in reducing graft loss or mortality. Compared with placebo/no induction, rATG and BAS appeared more effective in reducing biopsy-proven acute rejection (BPAR) and BAS appeared more effective at improving GRF. For maintenance therapy, no treatment was better for all outcomes and no treatment appeared most effective at reducing graft loss. BEL + MMF appeared more effective than TAC + MMF and SRL + MMF at reducing mortality. MMF + CSA (ciclosporin), TAC + MMF, SRL + TAC, TAC + AZA (azathioprine) and EVL + CSA appeared more effective than CSA + AZA and EVL + MPS at reducing BPAR. SRL + AZA, TAC + AZA, TAC + MMF and BEL + MMF appeared to improve GRF compared with CSA + AZA and MMF + CSA. In the base-case deterministic and probabilistic analyses, BAS, MMF and TAC were predicted to be cost-effective at £20,000 and £30,000 per quality-adjusted life-year (QALY). When comparing all regimens, only BAS + TAC + MMF was cost-effective at £20,000 and £30,000 per QALY.LimitationsFor included trials, there was substantial methodological heterogeneity, few trials reported follow-up beyond 1 year, and there were insufficient data to perform subgroup analysis. Treatment discontinuation and switching were not modelled.Future workHigh-quality, better-reported, longer-term RCTs are needed. Ideally, these would be sufficiently powered for subgroup analysis and include health-related quality of life as an outcome.ConclusionOnly a regimen of BAS induction followed by maintenance with TAC and MMF is likely to be cost-effective at £20,000–30,000 per QALY.Study registrationThis study is registered as PROSPERO CRD42014013189.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Survival Acute Rejection and Graft Loss After Transplantationmentioning

confidence: 99%

“…MMF was cost-effective at £20,000 and £30,000 per QALY for all n from 1 to 20. For lower values of n (up to [4][5][6][7][8], CSA was cost-effective at £20,000 or £30,000 per QALY, whereas for higher values (towards the base case), TAC was cost-effective at £20,000 and £30,000 per QALY.…”

Section: Eliminating Graft Survival Differences After a Certain Timementioning

confidence: 99%

Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model

Jones-Hughes

Snowsill

Haasova

et al. 2016

Health Technol Assess

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“…1,2 In the scheme, 6 general categories were developed, which included, in order of severity and occurrence in time, hyperacute rejection, acute cellular rejection, borderline rejection, humoral rejection, chronic rejection, and normal. Antibodymediated rejection was introduced in 1997 and defined morphologically.…”

Section: Discussionmentioning

confidence: 99%

Transplant Kidney With Acute Humoral Rejection Diagnosed by Needle Core Biopsy—A Case Report With Review of Pathological Morphology

Aufman¹

2015

Pathology Case Reviews

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Needle core biopsy is an important procedure used to evaluate transplanted kidneys. By examining the morphological findings, the pathologist can inform the nephrologist of certain findings that help guide the therapeutic management to prolong the life of the transplant kidney. The request for a kidney biopsy is usually decided as soon as signs and symptoms of renal dysfunction are noticed by the nephrologist, and therefore, most biopsies of the transplanted kidneys usually have some type of morphological pathology, which may be minimal because of the acute awareness of early rejection. This review discusses the history of acute antibody-mediated rejection and the morphological findings seen in humor rejection of the transplanted kidney.

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“…It was also noted from the trials that acute rejections were not as severe in the alemtuzumab group. The histological characteristics of the rejection episodes fell in BANFF I and BANFF II (moderate) in the alemtuzumab groups and BANFF III in control groups (The Banff Schema is described in the report of the Third Banff Conference, Banff, Canada [81] ). Moreover, the acute rejections were reversible in the alemtuzumab group [73,82] .…”

Section: Alemtuzuamb In Renal Transplantationmentioning

confidence: 99%

Immunomodulator alemtuzumab therapy in kidney transplantation

2016

Macrophage

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Owing to an insufficient understanding of molecular mechanisms, currently the best treatment available for chronic kidney failure is transplantation. There is a heightened need for effective immunosuppressants to counteract rejection. Alemtuzumab, a humanized anti-CD52 antibody, is a powerful lymphocyte-depleting agent. Recently, it has been increasingly used as induction therapy in renal transplantation but its role is not yet fully defined. Indications that early withdrawal of corticosteroids in kidney transplant patients is associated with a better prognosis, has necessitated a hunt for an effective induction agent that supports early corticosteroid withdrawal. In this regard, alemtuzumab is an attractive agent because of its prolonged lymphocyte depleting properties. Long-term studies in kidney transplant patients are still needed for it to be considered as an effective induction agent. Trends in lower acute rejection rates in groups using alemtuzumab induction, particularly in association with tacrolimus maintenance therapy, have been noted and acute rejections were not as severe. Lymphocyte depletion is expected to be associated with an increased incidence of infection and any new immunosuppressive agents should be observed closely for development of infection. Initial studies have not established increased infection rates with alemtuzumab induction, possibly because of the preservation of function of the remaining T-lymphocytes other than CD4+ cells. Further randomized control trials with larger populations are needed to draft a protocol for alemtuzumab's more effective use in transplantation.

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The evolution of the Banff classification schema for diagnosing renal allograft rejection and its implications for clinicians

Cited by 42 publications

References 19 publications

Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model

Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model

Transplant Kidney With Acute Humoral Rejection Diagnosed by Needle Core Biopsy—A Case Report With Review of Pathological Morphology

Immunomodulator alemtuzumab therapy in kidney transplantation

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