What are the ISHLT definition and diagnostic criteria for pulmonary antibody-mediated rejection (AMR)?

Updated: Aug 19, 2019
  • Author: Bryan A Whitson, MD, PhD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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In 2016, the International Society for Heart and Lung Transplantation (ISHLT) published a consensus opinion of the definition and diagnostic criteria for pulmonary antibody-mediated rejection (AMR). AMR as categorized as either clinical or subclinical with the following definitions [52]

  • Clinical AMR – "The presence of allograft dysfunction (defined as alterations in pulmonary physiology, gas exchange properties, radiologic features or deteriorating functional performance) associated with AMR. Clinical AMR may be asymptomatic, such as a small but significant change in pulmonary physiology."
  • Sub-clinical AMR – "Histologic criteria of AMR detected on surveillance transbronchial biopsies (with or without C4d and with or without the presence of DSA) in the absence of allograft dysfunction."

Clinical AMR is further categorized by ISHLT as definite, probable and possible based on the degree of certainty of the presence or absence of a number of pathologic, serologic, clinical, and immunologic criteria that include the following [52] :

  • Presence of donor-specific anti–human leukocyte antigen (HLA) antibodies (DSA)
  • Characteristic lung histology
  • Evidence of complement 4d (C4d) within the graft

Exclusion of other causes of allograft dysfunction increases confidence in the diagnosis but is not essential. 

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