Kim Solez

Images from 1991

.

The Banff Schema

was first developed by a group of pathologists,

nephrologists, and transplant surgeons at a

meeting in Banff Canada August 2-4, 1991..

It has continued to evolve through meetings every two years and has become the worldwide standard for interpretation of transplant biopsies.

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A moderated self-organizing group to define and standardize organ allograft biopsy interpretation

Aim is to promote international uniformity in reporting allograft pathology, which is necessary for research, clinical trials, and standardized patient management

International and inter-disciplinary process with meetings every 2 years

Mini-review “The Banff Classification Revisited” (Solez, K. and Racusen, L.C.) will be appearing in Kidney International later this year.

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In 1990 all standard textbooks were inaccurate in interpretation of kidney transplant biopsies◦ Suggesting, for example, that arteritis meant that the

kidney was doomed and antirejection treatment should be abandoned

It became imperative for the field to correct this and standardize interpretation

• Began in kidney (Solez et al. 1993), and was then extended to liver, pancreas, composite tissue grafts etc. Meetings also consider heart, lung, small bowel.

• Uses semi-quantitative lesion scoring 0-3+ and diagnostic categories.

Normal Antibody-mediated rejection, Borderline changes: ‘Suspicious’ for acute cellular

rejection T-cell-mediated rejection (may coincide with

categories 2 and 5 and 6) Sclerosis, interstitial fibrosis, and tubular atrophy,

no evidence of any specific etiology Other changes not considered to be due to

rejection

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Transplant glomerulitis - g Chronic transplant glomerulopathy - cg Interstitial Inflammation - i (ti) Interstitial fibrosis - ci Tubulitis - t Tubular atrophy - ct Vasculitis, intimal arteritis - v Fibrous intimal thickening - cv Arteriolar hyaline thickening - ah (aah) Mesangial matrix increase - mm Peritubular capillary cell accumulation - ptc

Genome Canada transplant transcriptome project.

Traditional pathology techniques.

Affymetrix GeneChip® probe array. Affymetrix GeneChip® probe array. Image courtesy of Affymetrix.Image courtesy of Affymetrix.

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1991 First Conference 1993 First Kidney International publication 1995 Integration with CADI 1997 Integration with CCTT classification 1999 Second KI paper. Clinical practice guidelines. Implantation biopsies,

microwave. 2001 Classification of antibody-mediated rejection◦ Regulatory agencies participating

2003 Genomics focus, ptc cell accumulation scoring 2005 Gene chip analysis. Elimination of CAN, identification of chronic

antibody-mediated rejection. 2007 First meeting far from a town called “Banff” – La Coruna, Spain. 2009 Working groups. Meeting in Banff, Alberta, Canada for last time until

2015!

86% Kidney clinical6% Liver clinical5% Kidney experimental1% Liver experimental

Most articles are in high quality journals with impact factor of 3.2 or higher, one third have impact factors of 6-9.

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The Banff meeting reports and main meeting papers have been cited 4,312 times in the medical literature.

The 1999 paper The Banff 97 Working Classification of Renal Allograft Pathology Kidney International 55(2):713-23, 1999 by Racusen, Solez, and Colvin et al. is a citation classic in the field having been cited 1,764 times.

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Classification begun at 1991 Banff meeting has become the worldwide standard, and the consensus process has now extended to all solid organs. Future meetings are planned every two years through 2019.

Standardization principles now being extended from biopsy reporting to tissue typing, imaging, all the other elements in transplant care.

Classification used in clinical trials, and by the FDA, mandatory evaluation for drug approvals.

Isolated v-lesionWorking Group

IHC Quality Assurance Working Group

Glomerular LesionWorking Group

Polyoma Virus Nephropathy Working Group

Fibrosis Scoring Working Group

Data-driven & Validated Refinement of the Banff Guidelines

Banff Working Groups:Addressing unmet needs in a data-driven, evidence based approach

Sis et al. 2009 Banff Meeting Report, Am J Transplant. 2010 Mar;10(3):464-71

C4d-Negative ABMRWorking Group

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Isolated V lesion – Banu Sis and Ed Kraus Fibrosis scoring – Robert Colvin Polyoma virus staging – Volker Nickeleit Glomerular lesion scoring – Mark Haas Molecular pathology – Phil Halloran Quality assurance IHC – Michael Mengel C4d neg. Ab-Mediated Rejection – Banu Sis History&Impact of Banff Process – Kim Solez

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1. Defining appropriate thresholds for microvascular injury and for DSA that provide an optimal balance of specificity and sensitivity for ABMR, noting that none of these morphologic changes are specific and that not all patients with DSA have ABMR.

2. Defining "C4d-negative". There is some evidence that focal C4d is often (though less so than diffuse C4d) associated with DSA and microvascular injury.

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3. Defining acute versus chronic/active Ab-mediated rejection.

4. Defining the significance of intimal arteritis

(in the absence of necrosis) as histologic evidence for Ab-mediated rejection.

Includes analysis of physician facilitation of consensus discussions, seen most recently in Bob Colvin’s C4d discussions and in Michael Mengel’s organization of Banff Working Groups. Also includes analysis of future trends and developments.

Future concepts of where technology is taking us are incorporated into long term planning of Banff Process.

Will be part of 2013 meeting in Brazil.

• Until now we have had none beyond Drs. Racusen and Solez.

• Will form Swiss foundation legal entity in 2012, to enable us to enter into formal relationships with other organizations we cannot do now.

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To lead development and dissemination of the international Banff Classification of Allograft Pathology and to facilitate multidisciplinary, collaborative research to enhance its scientific basis and clinical utility to improve the care of transplant patients.

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Facilitation of knowledge generation and translation in transplantation pathology with the ultimate aim to improve patient outcome

Maintaining the Banff spirit of a multinational, multidisciplinary consensus group

Fundraising Guidance and financial support for Working Group

activities Guidance and financial support for Banff meetings

activities

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Responsible for annual reports of the Foundation and adherence to Swiss law

Fiduciary responsibility for foundation funds Final responsibility for selection and content of Banff meetings Support and guide Working Group activities External representation of the Banff process: fundraising, policy

papers, set up, content, and maintenance of a Banff website Bidirectional communication to membership of the Banff community Composition:◦ The BOD consists of 6-9 members, including the Chair.

◦ Members are selected by majority vote of the BOD and serve for a 3 year term, renewable once. Terms are staggered (3 selected each year).

◦ The Chair and Secretary/Treasurer are selected by a majority vote of the BOD and serve for a 3 year term, renewable once.

◦ Vacancies filled by majority vote of BOD.

Secretary/Treasurer◦ Responsible for day-to-day business/activities of the Banff Foundation

and annual reporting

◦ Is a member of the board and regularly reports to the other board members

◦ Prepares annual budget and projections

◦ Monitors expenses

◦ Works closely with the administrative team

Flow and handling of funds through the A foundation should generate funding from whatever sources over its

lifetime, to fulfil its purpose; which in this case would be to run Banff meetings and to foster advances organ transplantation

Therefore the recommendation is to run any money e.g. from a pharmaceutical company into the Swiss Foundation, which then will at the Board of Trustees instruction transferred to a trusted organising committee, e.g. a University or Society account from local Banff meeting organizers , or Banff working group leaders for supporting their activities

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Organization of meetings together with local organizers Organization of cross-organ plenary sessions Program finalization according to input from Organ

Steering committees Selection of speakers and moderators Support and coordination of preparation of meeting

reports Terms of references:◦ Appointed by the BOD

◦ terms of membership four years (i.e. two meetings), renewable through majority vote of the board

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Should engage pathologists and clinicians as well as representative from major geographic regions (e.g. North America, South America, Europe, Asia, Africa, Australia)

Fund raising for the meetings and consensus work should also be scope for the organ steering committee members

Organization of organ specific sessions: selection of topics and speakers

Preparation of organ specific meeting reports Terms of reference:◦ Leadership appointed by the board of directors for four years (i.e.

two meetings), renewable through majority vote of the board

◦ Otherwise self-organized