Banff 2022/2024 Rejection Pathway (Diagnosis, Timing, Treatment)
Work through the Banff 2022/2024 diagnostic pathway for a kidney allograft: combine biopsy lesion scores, DSA status, and donor-derived cell-free DNA to reach one rejection diagnosis and a treatment plan the whole transplant team agrees on.
When to use it
Use when a transplant biopsy or a rising creatinine raises the question of rejection. The pathway separates active antibody-mediated rejection, T-cell-mediated rejection, borderline changes, and chronic scarring, and flags when dd-cfDNA above 1 percent supports an active process.
Category
Transplantation
References
- Naesens M et al. The Banff 2022 Kidney Meeting Report: Reappraisal of microvascular inflammation and the role of biopsy-based transcript diagnostics. Am J Transplant. 2024;24:338-349. PMID: 38032300
- Naesens M et al. The Banff 2024 Kidney Meeting Report: Rejection as a spectrum of phenotypes and focus on differential diagnostic reasoning. Am J Transplant. 2026;26:922-936. PMID: 41888020
- KDIGO 2009 Clinical Practice Guideline for the Care of Kidney Transplant Recipients. https://kdigo.org/guidelines/transplant-recipient/
Common clinical questions
- A transplant biopsy shows t2 i2 with IFTA 40 percent — how do I classify and treat it?
- t2 i2 with no intimal arteritis meets Banff Grade IA T-cell-mediated rejection (Grade IB requires severe tubulitis, t3). Treat active TCMR with pulse corticosteroids, adding anti-thymocyte globulin for steroid-resistant or vascular rejection. IFTA of 40 percent is established chronic scarring that will not reverse, so optimise maintenance immunosuppression and adherence rather than escalating therapy for the scar itself.
- When does dd-cfDNA change Banff decision-making?
- Donor-derived cell-free DNA above roughly 1 percent supports an active rejection process and is most useful when the biopsy is borderline or when clinical suspicion is high but a biopsy is delayed. A low dd-cfDNA makes active rejection less likely but does not exclude it.
About NephroMind
This calculator is part of NephroMind, a free clinical decision-aid platform from the Arab Society of Nephrology and Renal Transplantation (ASNRT) — over 128 bedside nephrology calculators plus a renal drug-dosing database, coded by a practicing transplant nephrologist.