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 = 16 774 posttransplant 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.