A 40-year-old woman undergoes renal transplantation from a cadaveric donor. She develops acute cellular rejection on day 12 confirmed by Banff Grade IIA rejection on renal biopsy. The Banff classification 2022 Grade IIA indicates:

• A Moderate-severe intimal arteritis (v2) comprising ≥25% luminal area loss
• B Transmural arteritis with fibrinoid necrosis (v3)
• C Mild-moderate intimal arteritis (v1) in ≥1 arterial cross-section ✓
• D Severe tubulitis (t3) with >10 mononuclear cells per tubular cross section

Explanation

The Banff classification of renal allograft pathology (2022 update) grades vascular rejection as: v1 — mild-to-moderate intimal arteritis in ≥1 arterial cross-section (Banff Grade IIA acute T-cell mediated rejection); v2 — severe intimal arteritis comprising ≥25% luminal area loss (Grade IIB); v3 — transmural arteritis or fibrinoid change with medial smooth muscle necrosis (Grade III). Grade IIA (v1) indicates acute vascular rejection requiring augmented immunosuppression. Tubulitis (t3) alone without vascular involvement constitutes Grade IA/IB rejection, not Grade IIA. Arteritis (v-lesions) in Banff grading is critical for management decisions.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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