Classification and grading of pulmonary allograft rejection

A: Acute rejection*: characterized by perivascular and interstitial mononuclear cell infiltrates

Grade 0: none

Grade 1: minimal

Grade 2: mild

Grade 3: moderate

Grade 4: severe

B: Airway inflammation (lymphocytic bronchiolitis)*: characterized by mononuclear cell infiltrates in the submucosa of bronchioles

Grade 0: none

Grade 1R^¶: low grade

Grade 2R^¶: high grade

Grade X: ungradeable

C: Chronic airway rejection (bronchiolitis obliterans): manifest by fibrous scarring that is often dense and eosinophilic

0: absent

1: present

D: Chronic vascular rejection - accelerated graft vascular sclerosis: characterized by fibrointimal thickening of the pulmonary arteries and veins. These lesions are not seen on TBB as they affect larger blood vessels than those accessed with TBB.

TBB: transbronchial biopsy.
* Acute vascular rejection (A1 to A4) and acute airway inflammation (B1 to B2R) can be seen independently or may both be present.
¶ "R" denotes revised grade to avoid confusion with 1996 scheme.

Reproduced from: Stewart S, Fishbein MC, Snell GI, et al. Revision of the 1996 working formulation for the standardization of nomenclature in the diagnosis of lung rejection. J Heart Lung Transplant 2007; 26:1229. Table used with the permission of Elsevier Inc. All rights reserved.

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Classification and grading of pulmonary allograft rejection