Renal graft survival according to Banff 2013 classification in indication biopsies

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array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1427 "Ancho" => 2732 "Tamanyo" => 189057 ] ] "descripcion" => array:1 [ "en" => "Distribution of histological diagnoses according to time after transplant. Ab: antibodies; IFTA: interstitial fibrosis/tubular atrophy; T-mediated: T cell-mediated rejection." ] ] ] "textoCompleto" => "IntroductionDue to the development of new immunosuppressive therapies in recent decades, the incidence of acute rejection has decreased considerably.<a class="elsevierStyleCrossRef" href="#bib0165">1</a> Short-term graft survival has also improved, going from a 9.1% probability of all-cause graft loss in the first year post-transplant in 2000 to 7.7% in 2011.<a class="elsevierStyleCrossRef" href="#bib0165">1</a> However, this benefit is not reflected in a significant improvement in long-term graft survival.<a class="elsevierStyleCrossRefs" href="#bib0170">2–4</a>It is necessary to seek strategies to improve long-term kidney graft survival. It is essential to study the causes and mechanisms involved in graft loss and to identify prognostic markers of graft loss better than those used classically, such as the estimated glomerular filtration rate or proteinurial. Although some studies have correlated a low estimated glomerular filtration rate after one year of transplantion with a higher rate of long-term graft failure, its predictive value for graft loss is limited.<a class="elsevierStyleCrossRefs" href="#bib0185">5–7</a> Proteinuria is also a kidney function marker with actual and predictive value; but the values of proteinuria may be affected by many factors such as infections, intercurrent diseases, etc., and its onset often reflects previously established kidney damage.<a class="elsevierStyleCrossRef" href="#bib0200">8</a>Renal biopsy (RB) provides very valuable information in terms of diagnostic and prognostic assessment, as reflected in previous studies mostly based on RB performed by protocol, which allows the identification of different lesions of histological patterns that are associated with worse graft survival.<a class="elsevierStyleCrossRefs" href="#bib0205">9–14</a> Thus, the Banff classification and the updates are based on the advances in the understanding of the pathophysiological mechanisms involved in renal graft injury. Lesions that previously had no diagnostic or prognosis value can be catalogued following a universal language, becoming a fundamental tool for assessing renal graft biopsies.<a class="elsevierStyleCrossRefs" href="#bib0235">15–23</a>However, there is little data from studies based on biopsies performed with indication, which focused primarily on establishing a relationship between a diagnosis of T cell-mediated rejection<a class="elsevierStyleCrossRefs" href="#bib0280">24,25</a> or antibody-mediated rejection with a worse graft outcome,<a class="elsevierStyleCrossRefs" href="#bib0290">26–28</a> and no information, about the prognostic value for the rest of the histological patterns.The objective of this study was to analyse the RBs with indication conducted in a cohort of kidney transplant patients. Then, reclassify these RB according to the recent Banff 2013 classification,<a class="elsevierStyleCrossRef" href="#bib0275">23</a> and to establish the prognostic value of graft survival according to the different diagnostic categories.MethodsA retrospective study was conducted based on the findings from 495 transplant RBs, performed with indication (kidney function deterioration, proteinuria, or microhaematuria), in 322 patients at the Hospital del Mar (Barcelona, Spain) between 1990 and 2014.The histopathological reports from those biopsies were reviewed by two authors of the present manuscript (DRP and MJPS) who reclassified the histological findings according to the Banff 2013 classification categories<a class="elsevierStyleCrossRef" href="#bib0275">23</a>: category 1: normal RB, category 2: antibody-mediated changes, category 3: borderline changes, category 4: T cell-mediated changes, category 5: interstitial fibrosis and tubular atrophy (IFTA), and category 6: other (changes not considered secondary to rejection). In such a case that histopathological reports contained insufficient information to be reclassified into any of the above described categories (n=37), two pathologists (JG and ISG) reassessed the available tissue samples and performed additional histological techniques required to made specific diagnosis (mostly C4d staining) If the reports contained data compatible with several categories, the predominant histological findings with the greatest prognostic weight were taken into account for the purpose of assigning a single category to each biopsy; therefore the diagnoses were exclusive.Furthermore, aiming of categorise the diagnoses with a potential association with a better or worse renal prognosis, the histological diagnoses were divided into two groups: 1) favourable histology: which included samples with normal histology or with minimal changes, acute tubular necrosis (ATN), or mild IFTA; 2) unfavourable histology: which included cases with diagnoses of chronic antibody-mediated rejection (samples with transplant glomerulopathy (cg>0)±positive C4d staining (focal or diffuse) in peritubular capillaries ± peritubular capillary basement membrane multi-layering ± new onset intimal fibrosis with no other attributable cause) or moderate-severe IFTA. This division was made based on previous studies relating these histological patterns with worse graft survival.<a class="elsevierStyleCrossRefs" href="#bib0230">14,29</a>Patients were followed from the time of the RB until loss of the graft (defined as return to dialysis or retransplant) or the patient's death. The statistical study included a Kaplan–Meier survival curve, using the log-rank test. Cox regression was used to calculate the risk of graft loss. The level of significance was set at p<0.05 and 95% for the confidence interval. The SPSS software package version 20.0 was used for the statistical calculations.ResultsThe analysis included 495 RBs from 322 patients, 62.7% of them male, with a mean age at the time of the kidney transplant (KT) of 47.2±13.8 years. The median time from KT until the RB was 12 months [IQR 1–51.5]. The median follow-up from the time of the RB was 21 months [IQR 7–65]. Histological diagnoses were reclassified according to the Banff 2013 classification categories. The histological findings did not allow for a conclusive diagnosis in 28 RBs (5.7%). Of the remaining 467, 51 (10.9%) were classified as normal (category 1), 97 (20.8%) as changes mediated by antibodies (category 2), 29 (6.2%) as borderline changes (category 3), 43 (9.2%) as T cell-mediated rejection (category 4), 116 (24.8%) as IFTA (category 5), and 131 (28.1%) as other diagnoses (category 6) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Among the category 5 (IFTA) biopsies, 63 (54.4%) were graded as mild, 30 (25.8%) moderate, and 23 (19.8%) severe. Among the category 6 or other diagnoses, the most common histological diagnoses were ATN in 53 cases (40.5%), followed by recurrent glomerular disease in 24 (18.3%) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The most common diagnoses were analysed relative to time after transplant. During the first years after the transplant a large proportion of biopsies were classified within categories 1, 3, 4, and 6; with more prolonged time after transplantation the high proportion of categories 1, 3, 4, and 6 was reduced in favour of an increase in biopsies classified as categories 2 and 5 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Graft survival (censored by death) 21 months after the RB, according to the Banff 2013 category in which RB was classified was: 70% for category 1, 45% for category 2, 69% for category 3, 56% for category 4, 51% for category 5, and 50% for category 6 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The risk of graft loss according to the category (taking category 1 as the reference) was highest in category 2 (HR 4.29, 95% CI: 2.39–7.73; p<0.001) and category 5 (HR 2.4; 95% CI: 1.36–4.27; p=0.003). The impact of T cell-mediated rejection on graft survival was not significant (HR 0.98; 95% CI: 0.90–3.19; p=0.98) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>According to the previously described as histological diagnoses with high prognostic value,<a class="elsevierStyleCrossRef" href="#bib0290">26</a> 276 RBs were classified as having a favourable (n=152) or unfavourable histology (n=124). A better graft survival was observed with biopsies in the favourable histology category as compared with those with unfavourable histology (35 vs. 20%; p<0.001), and the risk of graft loss was twofold with unfavourable histology (HR 2.2; 95% CI: 1.51–3.14; p<0.001) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>DiscussionIn this study we have analysed the results from a wide series of RBs with indication. We reanalysed them according to the Banff 2013 classifications and established what was the prognosis in terms of renal survival in each diagnostic category. The findings compatible with antibody-mediated rejection or moderate-severe IFTA confer the highest risk of graft loss.The objective of the first meeting of pathologists and nephrologists held in Banff in 1991 was to define and classify the histopathological findings found in kidney transplant biopsies. Until that time, the only diagnosis that was significant and treatable was acute rejection. In subsequent meetings, the diagnostic categories were updated, adapting them to advances in the understanding of the pathophysiology of graft loss and to a better characterisation of antibody-mediated injury. A correct classification of the histopathological diagnoses may clarify clinical conditions previously not well-defined or even underdiagnosed. In this study, the RB were reclassified according to Banff 2013<a class="elsevierStyleCrossRef" href="#bib0275">23</a> and it made possible to obtain a specific histological diagnosis in 95% of the biopsies, which illustrate the high diagnostic efficiency obtained with the RBs by performed with indication. The most common category was “other diagnoses” (28%), and within that category, diagnoses of ATN and recurring glomerular disease were most frequent. The next most common category was IFTA (24.8%), categorised as mild in 50% of our cases. Prior studies conducted in biopsies with indication showed heterogeneous results regarding the most common diagnoses. In a multi-centre study, Sellares et al.<a class="elsevierStyleCrossRef" href="#bib0290">26</a> prospectively assessed a cohort of 315 KT recipients in whom a RB had been performed due to graft dysfunction (412 biopsies) to identify the losses and to try to assign a cause to each of them. They reported that the most common category was a normal RB, or one with no big abnormalities in 29%, following by antibody-mediated changes in 18%.Sis et al.<a class="elsevierStyleCrossRef" href="#bib0310">30</a> evaluated 234 biopsies from 173 KT patients performed 16 months (as a mean) after the transplant; using the Banff 2007 classification criteria, they found that the most common diagnosis was T cell-mediated rejection (19%), followed by “other diagnoses”(17%). In this study, IFTA and C4d-positive antibody-mediated rejection accounted for only 5% and 7% of the diagnoses, respectively.Therefore, based on our data, the overall analysis of the frequency of the different diagnoses would not provide valuable prognostic information, since, as we can observe in both this study and others, the most common diagnoses varied substantially depending on the time elapsed after transplant. In our cohort, we observed that categories such as “normal” biopsy, ATN, and T cell-mediated changes were detected at a higher frequency in the RBs performed during the first year after the transplant. T cell-mediated changes were found in 15% of the biopsies performed during the first 6 months, whereas in biopsies performed 5 years after the transplant, this diagnosis only accounted for 2.5%. Furthermore, diagnoses such as antibody-mediated damage and chronic damage from different causes<a class="elsevierStyleCrossRef" href="#bib0315">31</a> (represented by IFTA) were more commonly found in late biopsies. In the case of antibody-mediated damage, it increased from 17.2% of RBs performed before the 6th month to 46% of biopsies performed between the 3rd and 5th year after transplant. In the case of IFTA, it also increased from 6.6% in early biopsies to 36% in biopsies after 5 years. Sellares et al. reported similar results, with a clear increase in the frequency of a histological diagnosis of antibody-mediated rejection in relation to the time passed after transplant and a decrease in the frequency of T cell-mediated rejection.<a class="elsevierStyleCrossRef" href="#bib0290">26</a>By analysing the prognosis of graft loss according to the assigned Banff 13 diagnostic category, we observe that as previously described, the risk of graft loss is fourfold increased in the transplants with RBs compatible with antibody-mediated rejection.<a class="elsevierStyleCrossRefs" href="#bib0230">14,26–28,32</a> The other histological pattern that was correlated with worse survival was moderate-severe IFTA, which does not correspond to a specific diagnosis but rather to a histological description with no weight of specificity; therefore, for a correct characterisation of the patient with IFTA it is necessary to obtain better diagnostic and prognostic information. On these lines, El-Zhogbi et al. found that 30.7% of kidney biopsies with graft loss had an IFTA diagnosis.<a class="elsevierStyleCrossRef" href="#bib0320">32</a> When reassessing the RBs, 80.9% of these generic IFTA diagnoses could be attributed to a specific cause, such as BK polyomavirus-induced nephropathy, antibody-mediated rejection, or multiple episodes of acute cellular rejection.Despite the fact that classically, acute rejection has been correlated with worse graft survival,<a class="elsevierStyleCrossRefs" href="#bib0280">24,25</a> in our kidney transplant cohort T cell-mediated rejection and a diagnosis of borderline changes had no significant impact on the kidney graft prognosis, which indicates that the weight classically attributed to this condition regarding its impact on graft survival could be categorized into antibody-mediated rejection. Excluding acute cellular rejection and antibody-mediated rejection from the survival analysis, the group including chronic antibody-mediated rejection and the presence of moderate-severe IFTA (unfavourable histology) shows a double risk of graft loss than the favourable histology. Therefore, these two conditions are postulated to provide the highest specific weight when predicting long-term graft survival.The main limitation of our study is the retrospective nature of the biopsy analysis; this made difficult to obtain complete information to determine whether the findings obtained in the RBs were the direct cause of the graft loss. Therefore, a causal relationship could not be establish.However, RB with indication continues to be the basic diagnostic tool for studying graft dysfunction. We did not find any published studies that analyse the prognostic value according to the different Banff 2013 categories. Our study provides important information about the specific weight on graft survival of these categories in a wide cohort of kidney transplant patients with a suitable follow-up time.In summary, the Banff 2013 classification enables specific diagnoses to be reassigned to previously unclassifiable biopsies. In our study, this established a higher percentage in the category “other diagnoses”, followed by the IFTA category and the antibody-mediated damage category. These last two categories emerged as the diagnoses with the greatest negative impact on graft survival. Moreover, we detected a very significant number of biopsies with advanced chronic damage, represented in the form of IFTA, without being able to attribute an aetiology. This likely illustrate the deficiencies of using histology only when analysing the causes of graft damage, and the limitation of biopsies with indication obtained for early detection of phenomena leading to chronic damage and reduction of graft survival. The strategies used for studying kidney damage and graft surveillance should combine clinical, analytical, and histological variables along with new techniques to achieve an early detection of specific causes responsible for graft damage.Authors/contributorsAll three authors contributed equally in the development of the study and in drafting the manuscript.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres803814" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec802005" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres803813" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec802006" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Authors/contributors" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-19" "fechaAceptado" => "2016-05-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec802005" "palabras" => array:4 [ 0 => "Renal transplant" 1 => "Renal biopsy" 2 => "Banff 2013 classification" 3 => "Graft survival" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec802006" "palabras" => array:4 [ 0 => "Trasplante renal" 1 => "Biopsia renal" 2 => "Clasificación de Banff 2013" 3 => "Supervivencia del injerto" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionThe impact of acute rejection in kidney graft survival is well known, but the prognosis of other diagnoses is uncertain. We evaluated the frequency and impact on graft survival of different diagnostic categories according to the Banff 2013 classification in a cohort of renal transplant recipients. Material and methodsRetrospective study of 495 renal biopsies by indication in 322 patients from 1990 to 2014. Two independent observers reviewed the histological reports, reclassifying according to the Banff 2013 classification. ResultsOf 495 biopsies, 28 (5.7%) were not diagnostic. Of the remaining 467, 10.3% were “normal” (category 1), 19.6% antibody-mediated changes (category 2), 5.9% “borderline” changes (category 3), 8.7% T-cell-mediated rejection (category 4), 23.4% interstitial fibrosis/tubular atrophy (IFTA) (category 5) and 26.5% with other diagnoses (category 6). As time after transplantation increases, diagnoses of categories 1, 3 and 4 decrease, while categories 5 and 2 increase. Worse graft survival with category 2 diagnosis was observed (45% at 7.5 years, HR 4.29 graft loss [95% CI, 2.39–7.73]; P≤0.001, compared to category 1). Grafts with “unfavourable histology” (chronic antibody-mediated rejection, moderate-severe IFTA) presented worse survival that grafts with “favourable histology” (normal, acute tubular necrosis, mild IFTA). ConclusionsThe Banff 2013 classification facilitates a histological diagnosis in 95% of indication biopsies. While diagnostic category 6 is the most common, a change in the predominant histopathology was observed according to time elapsed since transplantation. Antibody-mediated changes are associated with worse graft survival." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl impacto del rechazo agudo en la supervivencia del injerto renal es bien conocido; sin embargo, el pronóstico de otras entidades es incierto. Evaluamos la frecuencia y el impacto en la supervivencia del injerto de las diferentes categorías diagnósticas según la clasificación Banff 2013 en una cohorte de trasplantados renales y su impacto en la supervivencia del injerto. Material y métodosEstudio retrospectivo de 495 biopsias renales por indicación, en 322 pacientes entre 1990 y 2014. Dos observadores independientes revisaron los diagnósticos histológicos y reclasificaron según Banff 2013. ResultadosDe 495 biopsias, 28 (5,7%) fueron no diagnósticas. De las 467 restantes, 10,3% fueron «normales» (categoría 1), 19,6% fueron cambios mediados por anticuerpos (categoría 2), 5,9% fueron cambios borderline (categoría 3), el 8,7% fueron rechazo mediado por células T (categoría 4), el 23,4% fue fibrosis intersticial/atrofia tubular (FIAT) (categoría 5) y el 26,5% fueron otros diagnósticos (categoría 6). Al aumentar el tiempo postrasplante, disminuyen los diagnósticos de categorías 1, 3 y 4 y aumentan los de la 5 y la 2. Observamos peor supervivencia en injertos con diagnósticos de categoría 2 (45% a 7,5 años; HR pérdida del injerto 4,29 [IC 95%: 2,39-7,73]; p≤0,001, con respecto a categoría 1). Los injertos con «histología desfavorable» (rechazo crónico mediado por anticuerpos, IFTA moderada-severa) presentan peor supervivencia que los injertos con «histología favourable» (normal, necrosis tubular aguda, FIAT leve). ConclusionesLa clasificación de Banff 2013 permite el diagnóstico histológico en el 95% de las biopsias por indicación. La categoría 6 es la más frecuente, pero se observa una modificación en la histopatología predominante según el tiempo postrasplante. Los cambios mediados por anticuerpos se asocian con peor supervivencia del injerto." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Arias-Cabrales C, Redondo-Pachón D, Pérez-Sáez MJ, Gimeno J, Sánchez-Güerri I, Bermejo S, et al. Supervivencia del injerto renal según la categoría de Banff 2013 en biopsia por indicación. Nefrología. 2016;36:660–666." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1427 "Ancho" => 2732 "Tamanyo" => 189057 ] ] "descripcion" => array:1 [ "en" => "Distribution of histological diagnoses according to time after transplant. Ab: antibodies; IFTA: interstitial fibrosis/tubular atrophy; T-mediated: T cell-mediated rejection." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1465 "Ancho" => 2691 "Tamanyo" => 154314 ] ] "descripcion" => array:1 [ "en" => "Graft survival (censored by death) with renal biopsy with indication, according to the different Banff 2013 categories after 10 years of follow-up. IFTA: interstitial fibrosis/tubular atrophy; T-mediated rejection: T cell-mediated rejection." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1597 "Ancho" => 1679 "Tamanyo" => 129236 ] ] "descripcion" => array:1 [ "en" => "Graft survival (censored by death) with renal biopsy with indication, according to diagnoses included within the favourable or unfavourable histology group. RB: renal biopsy." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "KT: kidney transplant; IQR: interquartile range; RB: renal biopsy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of renal biopsies \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">495 (322 patients) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Banff 2013 diagnosis (n, %) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">467 (94.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male (n, %) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">300 (60.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age in years (mean, standard deviation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47.2±13.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">KT-RB time in months (median, IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 [1–51.5] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Post-RB follow-up in months (median, IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 [7–65] \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349408.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Overall results of the kidney transplant recipients to those who underwent renal biopsy with indication." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "IFTA: interstitial fibrosis/tubular atrophy; ATN: acute tubular necrosis." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Banff 2013 category \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal (category 1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 (10.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antibody-mediated changes (category 2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97 (20.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Borderline changes (category 3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (6.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T cell-mediated rejection (category 4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 (9.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IFTA (category 5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">116 (24.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 (54.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (25.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (19.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other diagnoses (category 6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">131 (28.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ATN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (40.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kidney disease relapse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (18.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349407.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Overall distribution of biopsies according to the Banff 2013 categories." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "IFTA: interstitial fibrosis/tubular atrophy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic categories \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><6 months n=197 (42.2%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">6–12 months n=44 (9.4%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1–3 years n=107 (22.9%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">3–5 years n=41 (8.7%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">>5 years n=78 (16.7%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal biopsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (13.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (18.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (11.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antibody-mediated changes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (17.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (13.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (17.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (19.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (38.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Borderline changes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (10.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (6.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T cell-mediated rejection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (15.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (6.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (7.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (2.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IFTA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (6.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (29.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (39.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">(48.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">(35.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 (36.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (25.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (23.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (21.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (17.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349406.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution of renal biopsies according to time after kidney transplant." ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "IFTA: interstitial fibrosis/tubular atrophy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Categories \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">HR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CI (95%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1: Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2: Antibody-mediated changes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.39–7.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3: Borderline changes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.53–2.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.638 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4: T cell-mediated rejection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.90–3.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.98 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5: IFTA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.36–4.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6: Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.16–3.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.013 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349409.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Risk of graft loss as compared to Banff 2013 category 1 (normal biopsy or with minimal changes)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib0165" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "US renal data system 2014 annual data report: Epidemiology of kidney disease in the United States" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:7 [ 0 => "R. 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Meier-Kriesche" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1600-6143.2010.03283.x" "Revista" => array:6 [ "tituloSerie" => "Am J Transplant" "fecha" => "2011" "volumen" => "11" "paginaInicial" => "450" "paginaFinal" => "462" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20973913" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0175" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lack of improvement in renal allograft survival despite a marked decrease in acute rejection rates over the most recent era" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H.U. Meier-Kriesche" 1 => "J.D. Schold" 2 => "T.R. Srinivas" 3 => "B. 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Meier-Kriesche" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1600-6143.2011.03539.x" "Revista" => array:7 [ "tituloSerie" => "Am J Transplant" "fecha" => "2011" "volumen" => "11" "paginaInicial" => "1226" "paginaFinal" => "1235" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21564524" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0090825808004563" "estado" => "S300" "issn" => "00908258" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0185" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Poor predictive value of serum creatinine for renal allograft loss" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Kaplan" 1 => "J. Schold" 2 => "H.U. 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Supervivencia del injerto renal según la categoría de Banff 2013 en biopsia por indicación

Carlos Arias-Cabralesa, Dolores Redondo-Pachóna, María José Pérez-Sáeza, Javier Gimenob, Ignacio Sánchez-Güerrib, Sheila Bermejoa, Adriana Sierraa, Carla Burballaa, Marisa Mira, Marta Crespoa, Julio Pascuala,

Corresponding author

julpascual@gmail.com

Corresponding author.

a Servicio de Nefrología, Hospital del Mar, Barcelona, Spain

b Anatomía Patológica, Hospital del Mar, Barcelona, Spain

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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of histological diagnoses according to time after transplant&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ab&#58; antibodies&#59; IFTA&#58; interstitial fibrosis&#47;tubular atrophy&#59; T-mediated&#58; T cell-mediated rejection&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Due to the development of new immunosuppressive therapies in recent decades&#44; the incidence of acute rejection has decreased considerably&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> Short-term graft survival has also improved&#44; going from a 9&#46;1&#37; probability of all-cause graft loss in the first year post-transplant in 2000 to 7&#46;7&#37; in 2011&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> However&#44; this benefit is not reflected in a significant improvement in long-term graft survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It is necessary to seek strategies to improve long-term kidney graft survival&#46; It is essential to study the causes and mechanisms involved in graft loss and to identify prognostic markers of graft loss better than those used classically&#44; such as the estimated glomerular filtration rate or proteinurial&#46; Although some studies have correlated a low estimated glomerular filtration rate after one year of transplantion with a higher rate of long-term graft failure&#44; its predictive value for graft loss is limited&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">5&#8211;7</span></a> Proteinuria is also a kidney function marker with actual and predictive value&#59; but the values of proteinuria may be affected by many factors such as infections&#44; intercurrent diseases&#44; etc&#46;&#44; and its onset often reflects previously established kidney damage&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Renal biopsy &#40;RB&#41; provides very valuable information in terms of diagnostic and prognostic assessment&#44; as reflected in previous studies mostly based on RB performed by protocol&#44; which allows the identification of different lesions of histological patterns that are associated with worse graft survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">9&#8211;14</span></a> Thus&#44; the Banff classification and the updates are based on the advances in the understanding of the pathophysiological mechanisms involved in renal graft injury&#46; Lesions that previously had no diagnostic or prognosis value can be catalogued following a universal language&#44; becoming a fundamental tool for assessing renal graft biopsies&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">15&#8211;23</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; there is little data from studies based on biopsies performed with indication&#44; which focused primarily on establishing a relationship between a diagnosis of T cell-mediated rejection<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">24&#44;25</span></a> or antibody-mediated rejection with a worse graft outcome&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">26&#8211;28</span></a> and no information&#44; about the prognostic value for the rest of the histological patterns&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this study was to analyse the RBs with indication conducted in a cohort of kidney transplant patients&#46; Then&#44; reclassify these RB according to the recent Banff 2013 classification&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">23</span></a> and to establish the prognostic value of graft survival according to the different diagnostic categories&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A retrospective study was conducted based on the findings from 495 transplant RBs&#44; performed with indication &#40;kidney function deterioration&#44; proteinuria&#44; or microhaematuria&#41;&#44; in 322 patients at the Hospital del Mar &#40;Barcelona&#44; Spain&#41; between 1990 and 2014&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The histopathological reports from those biopsies were reviewed by two authors of the present manuscript &#40;DRP and MJPS&#41; who reclassified the histological findings according to the Banff 2013 classification categories<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">23</span></a>&#58; category 1&#58; normal RB&#44; category 2&#58; antibody-mediated changes&#44; category 3&#58; <span class="elsevierStyleItalic">borderline</span> changes&#44; category 4&#58; T cell-mediated changes&#44; category 5&#58; interstitial fibrosis and tubular atrophy &#40;IFTA&#41;&#44; and category 6&#58; other &#40;changes not considered secondary to rejection&#41;&#46; In such a case that histopathological reports contained insufficient information to be reclassified into any of the above described categories &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>37&#41;&#44; two pathologists &#40;JG and ISG&#41; reassessed the available tissue samples and performed additional histological techniques required to made specific diagnosis &#40;mostly C4d staining&#41; If the reports contained data compatible with several categories&#44; the predominant histological findings with the greatest prognostic weight were taken into account for the purpose of assigning a single category to each biopsy&#59; therefore the diagnoses were exclusive&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Furthermore&#44; aiming of categorise the diagnoses with a potential association with a better or worse renal prognosis&#44; the histological diagnoses were divided into two groups&#58; 1&#41; favourable histology&#58; which included samples with normal histology or with minimal changes&#44; acute tubular necrosis &#40;ATN&#41;&#44; or mild IFTA&#59; 2&#41; unfavourable histology&#58; which included cases with diagnoses of chronic antibody-mediated rejection &#40;samples with transplant glomerulopathy &#40;cg<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#41;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>positive C4d staining &#40;focal or diffuse&#41; in peritubular capillaries &#177; peritubular capillary basement membrane multi-layering &#177; new onset intimal fibrosis with no other attributable cause&#41; or moderate-severe IFTA&#46; This division was made based on previous studies relating these histological patterns with worse graft survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14&#44;29</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients were followed from the time of the RB until loss of the graft &#40;defined as return to dialysis or retransplant&#41; or the patient&#39;s death&#46; The statistical study included a Kaplan&#8211;Meier survival curve&#44; using the log-rank test&#46; Cox regression was used to calculate the risk of graft loss&#46; The level of significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 and 95&#37; for the confidence interval&#46; The SPSS software package version 20&#46;0 was used for the statistical calculations&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The analysis included 495 RBs from 322 patients&#44; 62&#46;7&#37; of them male&#44; with a mean age at the time of the kidney transplant &#40;KT&#41; of 47&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;8 years&#46; The median time from KT until the RB was 12 months &#91;IQR 1&#8211;51&#46;5&#93;&#46; The median follow-up from the time of the RB was 21 months &#91;IQR 7&#8211;65&#93;&#46; Histological diagnoses were reclassified according to the Banff 2013 classification categories&#46; The histological findings did not allow for a conclusive diagnosis in 28 RBs &#40;5&#46;7&#37;&#41;&#46; Of the remaining 467&#44; 51 &#40;10&#46;9&#37;&#41; were classified as normal &#40;category 1&#41;&#44; 97 &#40;20&#46;8&#37;&#41; as changes mediated by antibodies &#40;category 2&#41;&#44; 29 &#40;6&#46;2&#37;&#41; as borderline changes &#40;category 3&#41;&#44; 43 &#40;9&#46;2&#37;&#41; as T cell-mediated rejection &#40;category 4&#41;&#44; 116 &#40;24&#46;8&#37;&#41; as IFTA &#40;category 5&#41;&#44; and 131 &#40;28&#46;1&#37;&#41; as other diagnoses &#40;category 6&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Among the category 5 &#40;IFTA&#41; biopsies&#44; 63 &#40;54&#46;4&#37;&#41; were graded as mild&#44; 30 &#40;25&#46;8&#37;&#41; moderate&#44; and 23 &#40;19&#46;8&#37;&#41; severe&#46; Among the category 6 or other diagnoses&#44; the most common histological diagnoses were ATN in 53 cases &#40;40&#46;5&#37;&#41;&#44; followed by recurrent glomerular disease in 24 &#40;18&#46;3&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The most common diagnoses were analysed relative to time after transplant&#46; During the first years after the transplant a large proportion of biopsies were classified within categories 1&#44; 3&#44; 4&#44; and 6&#59; with more prolonged time after transplantation the high proportion of categories 1&#44; 3&#44; 4&#44; and 6 was reduced in favour of an increase in biopsies classified as categories 2 and 5 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Graft survival &#40;censored by death&#41; 21 months after the RB&#44; according to the Banff 2013 category in which RB was classified was&#58; 70&#37; for category 1&#44; 45&#37; for category 2&#44; 69&#37; for category 3&#44; 56&#37; for category 4&#44; 51&#37; for category 5&#44; and 50&#37; for category 6 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The risk of graft loss according to the category &#40;taking category 1 as the reference&#41; was highest in category 2 &#40;HR 4&#46;29&#44; 95&#37; CI&#58; 2&#46;39&#8211;7&#46;73&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and category 5 &#40;HR 2&#46;4&#59; 95&#37; CI&#58; 1&#46;36&#8211;4&#46;27&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#46; The impact of T cell-mediated rejection on graft survival was not significant &#40;HR 0&#46;98&#59; 95&#37; CI&#58; 0&#46;90&#8211;3&#46;19&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;98&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">According to the previously described as histological diagnoses with high prognostic value&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a> 276 RBs were classified as having a favourable &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>152&#41; or unfavourable histology &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>124&#41;&#46; A better graft survival was observed with biopsies in the favourable histology category as compared with those with unfavourable histology &#40;35 vs&#46; 20&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; and the risk of graft loss was twofold with unfavourable histology &#40;HR 2&#46;2&#59; 95&#37; CI&#58; 1&#46;51&#8211;3&#46;14&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">In this study we have analysed the results from a wide series of RBs with indication&#46; We reanalysed them according to the Banff 2013 classifications and established what was the prognosis in terms of renal survival in each diagnostic category&#46; The findings compatible with antibody-mediated rejection or moderate-severe IFTA confer the highest risk of graft loss&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The objective of the first meeting of pathologists and nephrologists held in Banff in 1991 was to define and classify the histopathological findings found in kidney transplant biopsies&#46; Until that time&#44; the only diagnosis that was significant and treatable was acute rejection&#46; In subsequent meetings&#44; the diagnostic categories were updated&#44; adapting them to advances in the understanding of the pathophysiology of graft loss and to a better characterisation of antibody-mediated injury&#46; A correct classification of the histopathological diagnoses may clarify clinical conditions previously not well-defined or even underdiagnosed&#46; In this study&#44; the RB were reclassified according to Banff 2013<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">23</span></a> and it made possible to obtain a specific histological diagnosis in 95&#37; of the biopsies&#44; which illustrate the high diagnostic efficiency obtained with the RBs by performed with indication&#46; The most common category was &#8220;other diagnoses&#8221; &#40;28&#37;&#41;&#44; and within that category&#44; diagnoses of ATN and recurring glomerular disease were most frequent&#46; The next most common category was IFTA &#40;24&#46;8&#37;&#41;&#44; categorised as mild in 50&#37; of our cases&#46; Prior studies conducted in biopsies with indication showed heterogeneous results regarding the most common diagnoses&#46; In a multi-centre study&#44; Sellares et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a> prospectively assessed a cohort of 315 KT recipients in whom a RB had been performed due to graft dysfunction &#40;412 biopsies&#41; to identify the losses and to try to assign a cause to each of them&#46; They reported that the most common category was a normal RB&#44; or one with no big abnormalities in 29&#37;&#44; following by antibody-mediated changes in 18&#37;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Sis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">30</span></a> evaluated 234 biopsies from 173 KT patients performed 16 months &#40;as a mean&#41; after the transplant&#59; using the Banff 2007 classification criteria&#44; they found that the most common diagnosis was T cell-mediated rejection &#40;19&#37;&#41;&#44; followed by &#8220;other diagnoses&#8221;&#40;17&#37;&#41;&#46; In this study&#44; IFTA and C4d-positive antibody-mediated rejection accounted for only 5&#37; and 7&#37; of the diagnoses&#44; respectively&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Therefore&#44; based on our data&#44; the overall analysis of the frequency of the different diagnoses would not provide valuable prognostic information&#44; since&#44; as we can observe in both this study and others&#44; the most common diagnoses varied substantially depending on the time elapsed after transplant&#46; In our cohort&#44; we observed that categories such as &#8220;normal&#8221; biopsy&#44; ATN&#44; and T cell-mediated changes were detected at a higher frequency in the RBs performed during the first year after the transplant&#46; T cell-mediated changes were found in 15&#37; of the biopsies performed during the first 6 months&#44; whereas in biopsies performed 5 years after the transplant&#44; this diagnosis only accounted for 2&#46;5&#37;&#46; Furthermore&#44; diagnoses such as antibody-mediated damage and chronic damage from different causes<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">31</span></a> &#40;represented by IFTA&#41; were more commonly found in late biopsies&#46; In the case of antibody-mediated damage&#44; it increased from 17&#46;2&#37; of RBs performed before the 6th month to 46&#37; of biopsies performed between the 3rd and 5th year after transplant&#46; In the case of IFTA&#44; it also increased from 6&#46;6&#37; in early biopsies to 36&#37; in biopsies after 5 years&#46; Sellares et al&#46; reported similar results&#44; with a clear increase in the frequency of a histological diagnosis of antibody-mediated rejection in relation to the time passed after transplant and a decrease in the frequency of T cell-mediated rejection&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">By analysing the prognosis of graft loss according to the assigned Banff 13 diagnostic category&#44; we observe that as previously described&#44; the risk of graft loss is fourfold increased in the transplants with RBs compatible with antibody-mediated rejection&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14&#44;26&#8211;28&#44;32</span></a> The other histological pattern that was correlated with worse survival was moderate-severe IFTA&#44; which does not correspond to a specific diagnosis but rather to a histological description with no weight of specificity&#59; therefore&#44; for a correct characterisation of the patient with IFTA it is necessary to obtain better diagnostic and prognostic information&#46; On these lines&#44; El-Zhogbi et al&#46; found that 30&#46;7&#37; of kidney biopsies with graft loss had an IFTA diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">32</span></a> When reassessing the RBs&#44; 80&#46;9&#37; of these generic IFTA diagnoses could be attributed to a specific cause&#44; such as BK polyomavirus-induced nephropathy&#44; antibody-mediated rejection&#44; or multiple episodes of acute cellular rejection&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Despite the fact that classically&#44; acute rejection has been correlated with worse graft survival&#44;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">24&#44;25</span></a> in our kidney transplant cohort T cell-mediated rejection and a diagnosis of <span class="elsevierStyleItalic">borderline</span> changes had no significant impact on the kidney graft prognosis&#44; which indicates that the weight classically attributed to this condition regarding its impact on graft survival could be categorized into antibody-mediated rejection&#46; Excluding acute cellular rejection and antibody-mediated rejection from the survival analysis&#44; the group including chronic antibody-mediated rejection and the presence of moderate-severe IFTA &#40;unfavourable histology&#41; shows a double risk of graft loss than the favourable histology&#46; Therefore&#44; these two conditions are postulated to provide the highest specific weight when predicting long-term graft survival&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The main limitation of our study is the retrospective nature of the biopsy analysis&#59; this made difficult to obtain complete information to determine whether the findings obtained in the RBs were the direct cause of the graft loss&#46; Therefore&#44; a causal relationship could not be establish&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">However&#44; RB with indication continues to be the basic diagnostic tool for studying graft dysfunction&#46; We did not find any published studies that analyse the prognostic value according to the different Banff 2013 categories&#46; Our study provides important information about the specific weight on graft survival of these categories in a wide cohort of kidney transplant patients with a suitable follow-up time&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In summary&#44; the Banff 2013 classification enables specific diagnoses to be reassigned to previously unclassifiable biopsies&#46; In our study&#44; this established a higher percentage in the category &#8220;other diagnoses&#8221;&#44; followed by the IFTA category and the antibody-mediated damage category&#46; These last two categories emerged as the diagnoses with the greatest negative impact on graft survival&#46; Moreover&#44; we detected a very significant number of biopsies with advanced chronic damage&#44; represented in the form of IFTA&#44; without being able to attribute an aetiology&#46; This likely illustrate the deficiencies of using histology only when analysing the causes of graft damage&#44; and the limitation of biopsies with indication obtained for early detection of phenomena leading to chronic damage and reduction of graft survival&#46; The strategies used for studying kidney damage and graft surveillance should combine clinical&#44; analytical&#44; and histological variables along with new techniques to achieve an early detection of specific causes responsible for graft damage&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Authors&#47;contributors</span><p id="par0125" class="elsevierStylePara elsevierViewall">All three authors contributed equally in the development of the study and in drafting the manuscript&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2015-10-19"
    "fechaAceptado" => "2016-05-10"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec802005"
          "palabras" => array:4 [
            0 => "Renal transplant"
            1 => "Renal biopsy"
            2 => "Banff 2013 classification"
            3 => "Graft survival"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec802006"
          "palabras" => array:4 [
            0 => "Trasplante renal"
            1 => "Biopsia renal"
            2 => "Clasificaci&#243;n de Banff 2013"
            3 => "Supervivencia del injerto"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The impact of acute rejection in kidney graft survival is well known&#44; but the prognosis of other diagnoses is uncertain&#46; We evaluated the frequency and impact on graft survival of different diagnostic categories according to the Banff 2013 classification in a cohort of renal transplant recipients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of 495 renal biopsies by indication in 322 patients from 1990 to 2014&#46; Two independent observers reviewed the histological reports&#44; reclassifying according to the Banff 2013 classification&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of 495 biopsies&#44; 28 &#40;5&#46;7&#37;&#41; were not diagnostic&#46; Of the remaining 467&#44; 10&#46;3&#37; were &#8220;normal&#8221; &#40;category 1&#41;&#44; 19&#46;6&#37; antibody-mediated changes &#40;category 2&#41;&#44; 5&#46;9&#37; &#8220;borderline&#8221; changes &#40;category 3&#41;&#44; 8&#46;7&#37; T-cell-mediated rejection &#40;category 4&#41;&#44; 23&#46;4&#37; interstitial fibrosis&#47;tubular atrophy &#40;IFTA&#41; &#40;category 5&#41; and 26&#46;5&#37; with other diagnoses &#40;category 6&#41;&#46; As time after transplantation increases&#44; diagnoses of categories 1&#44; 3 and 4 decrease&#44; while categories 5 and 2 increase&#46; Worse graft survival with category 2 diagnosis was observed &#40;45&#37; at 7&#46;5 years&#44; HR 4&#46;29 graft loss &#91;95&#37; CI&#44; 2&#46;39&#8211;7&#46;73&#93;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; compared to category 1&#41;&#46; Grafts with &#8220;unfavourable histology&#8221; &#40;chronic antibody-mediated rejection&#44; moderate-severe IFTA&#41; presented worse survival that grafts with &#8220;favourable histology&#8221; &#40;normal&#44; acute tubular necrosis&#44; mild IFTA&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The Banff 2013 classification facilitates a histological diagnosis in 95&#37; of indication biopsies&#46; While diagnostic category 6 is the most common&#44; a change in the predominant histopathology was observed according to time elapsed since transplantation&#46; Antibody-mediated changes are associated with worse graft survival&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El impacto del rechazo agudo en la supervivencia del injerto renal es bien conocido&#59; sin embargo&#44; el pron&#243;stico de otras entidades es incierto&#46; Evaluamos la frecuencia y el impacto en la supervivencia del injerto de las diferentes categor&#237;as diagn&#243;sticas seg&#250;n la clasificaci&#243;n Banff 2013 en una cohorte de trasplantados renales y su impacto en la supervivencia del injerto&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de 495 biopsias renales por indicaci&#243;n&#44; en 322 pacientes entre 1990 y 2014&#46; Dos observadores independientes revisaron los diagn&#243;sticos histol&#243;gicos y reclasificaron seg&#250;n Banff 2013&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De 495 biopsias&#44; 28 &#40;5&#44;7&#37;&#41; fueron no diagn&#243;sticas&#46; De las 467 restantes&#44; 10&#44;3&#37; fueron &#171;normales&#187; &#40;categor&#237;a 1&#41;&#44; 19&#44;6&#37; fueron cambios mediados por anticuerpos &#40;categor&#237;a 2&#41;&#44; 5&#44;9&#37; fueron cambios <span class="elsevierStyleItalic">borderline</span> &#40;categor&#237;a 3&#41;&#44; el 8&#44;7&#37; fueron rechazo mediado por c&#233;lulas T &#40;categor&#237;a 4&#41;&#44; el 23&#44;4&#37; fue fibrosis intersticial&#47;atrofia tubular &#40;FIAT&#41; &#40;categor&#237;a 5&#41; y el 26&#44;5&#37; fueron otros diagn&#243;sticos &#40;categor&#237;a 6&#41;&#46; Al aumentar el tiempo postrasplante&#44; disminuyen los diagn&#243;sticos de categor&#237;as 1&#44; 3 y 4 y aumentan los de la 5 y la 2&#46; Observamos peor supervivencia en injertos con diagn&#243;sticos de categor&#237;a 2 &#40;45&#37; a 7&#44;5 a&#241;os&#59; HR p&#233;rdida del injerto 4&#44;29 &#91;IC 95&#37;&#58; 2&#44;39-7&#44;73&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#44; con respecto a categor&#237;a 1&#41;&#46; Los injertos con &#171;histolog&#237;a desfavorable&#187; &#40;rechazo cr&#243;nico mediado por anticuerpos&#44; IFTA moderada-severa&#41; presentan peor supervivencia que los injertos con &#171;histolog&#237;a favourable&#187; &#40;normal&#44; necrosis tubular aguda&#44; FIAT leve&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La clasificaci&#243;n de Banff 2013 permite el diagn&#243;stico histol&#243;gico en el 95&#37; de las biopsias por indicaci&#243;n&#46; La categor&#237;a 6 es la m&#225;s frecuente&#44; pero se observa una modificaci&#243;n en la histopatolog&#237;a predominante seg&#250;n el tiempo postrasplante&#46; Los cambios mediados por anticuerpos se asocian con peor supervivencia del injerto&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arias-Cabrales C&#44; Redondo-Pach&#243;n D&#44; P&#233;rez-S&#225;ez MJ&#44; Gimeno J&#44; S&#225;nchez-G&#252;erri I&#44; Bermejo S&#44; et al&#46; Supervivencia del injerto renal seg&#250;n la categor&#237;a de Banff 2013 en biopsia por indicaci&#243;n&#46; Nefrolog&#237;a&#46; 2016&#59;36&#58;660&#8211;666&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of histological diagnoses according to time after transplant&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ab&#58; antibodies&#59; IFTA&#58; interstitial fibrosis&#47;tubular atrophy&#59; T-mediated&#58; T cell-mediated rejection&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Graft survival &#40;censored by death&#41; with renal biopsy with indication&#44; according to the different Banff 2013 categories after 10 years of follow-up&#46;</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">IFTA&#58; interstitial fibrosis&#47;tubular atrophy&#59; T-mediated rejection&#58; T cell-mediated rejection&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Graft survival &#40;censored by death&#41; with renal biopsy with indication&#44; according to diagnoses included within the favourable or unfavourable histology group&#46;</p> <p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">RB&#58; renal biopsy&#46;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">KT&#58; kidney transplant&#59; IQR&#58; interquartile range&#59; RB&#58; renal biopsy&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of renal biopsies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">495 &#40;322 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Banff 2013 diagnosis &#40;<span class="elsevierStyleItalic">n</span>&#44; &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">467 &#40;94&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male &#40;<span class="elsevierStyleItalic">n</span>&#44; &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">300 &#40;60&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age in years &#40;mean&#44; standard deviation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">KT-RB time in months &#40;median&#44; IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#91;1&#8211;51&#46;5&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Post-RB follow-up in months &#40;median&#44; IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 &#91;7&#8211;65&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Overall results of the kidney transplant recipients to those who underwent renal biopsy with indication&#46;</p>"
        ]
      ]
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">IFTA&#58; interstitial fibrosis&#47;tubular atrophy&#59; ATN&#58; acute tubular necrosis&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Banff 2013 category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Normal &#40;category 1&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Antibody-mediated changes &#40;category 2&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97 &#40;20&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Borderline changes &#40;category 3&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29 &#40;6&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">T cell-mediated rejection &#40;category 4&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;9&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">IFTA &#40;category 5&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">116 &#40;24&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleItalic">63 &#40;54&#46;4&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleItalic">30 &#40;25&#46;8&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleItalic">23 &#40;19&#46;8&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Other diagnoses &#40;category 6&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">131 &#40;28&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ATN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleItalic">53 &#40;40&#46;5&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Kidney disease relapse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleItalic">24 &#40;18&#46;3&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Overall distribution of biopsies according to the Banff 2013 categories&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Diagnostic categories</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">&#60;6 months</span><br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>197 &#40;42&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">6&#8211;12 months</span><br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>44 &#40;9&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">1&#8211;3 years</span><br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>107 &#40;22&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">3&#8211;5 years</span><br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>41 &#40;8&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">&#62;5 years</span><br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>78 &#40;16&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal biopsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;13&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;11&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;3&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antibody-mediated changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;17&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;13&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;17&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;19&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;38&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Borderline</span> changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;10&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;6&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T cell-mediated rejection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;15&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;6&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;4&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;7&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;2&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IFTA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;6&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;29&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;39&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#40;48&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#40;35&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72 &#40;36&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;23&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;21&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;17&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Categories&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#58; Antibody-mediated changes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;39&#8211;7&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;53&#8211;2&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;638&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;90&#8211;3&#46;49&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;36&#8211;4&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;013&nbsp;\t\t\t\t\t\t\n
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:32 [
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                    0 => array:2 [
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                  "host" => array:1 [
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            1 => array:3 [
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                            1 => "S&#46; Lodhi"
                            2 => "H&#46;U&#46; Meier-Kriesche"
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            2 => array:3 [
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                      "titulo" => "Lack of improvement in renal allograft survival despite a marked decrease in acute rejection rates over the most recent era"
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                        0 => array:2 [
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                            0 => "H&#46;U&#46; Meier-Kriesche"
                            1 => "J&#46;D&#46; Schold"
                            2 => "T&#46;R&#46; Srinivas"
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                        "tituloSerie" => "Am J Transplant"
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            3 => array:3 [
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                      "titulo" => "Solid organ allograft survival improvement in the United States&#58; the long-term does not mirror the dramatic short term success"
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                        0 => array:2 [
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                            1 => "K&#46;E&#46; Lamb"
                            2 => "H&#46;U&#46; Meier-Kriesche"
                          ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1600-6143.2011.03539.x"
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                        "tituloSerie" => "Am J Transplant"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21564524"
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            4 => array:3 [
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                        0 => array:2 [
                          "etal" => false
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                            0 => "B&#46; Kaplan"
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                  ]
                  "host" => array:1 [
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            5 => array:3 [
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                  "contribucion" => array:1 [
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                          "etal" => true
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                  "host" => array:1 [
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Article information

ISSN: 20132514
Original language: English

DOI:10.1016/j.nefroe.2016.05.012

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Year/Month	Html	Pdf	Total

2024 November	7	2	9
2024 October	51	57	108
2024 September	56	33	89
2024 August	85	86	171
2024 July	69	33	102
2024 June	74	42	116
2024 May	67	42	109
2024 April	79	35	114
2024 March	73	26	99
2024 February	69	38	107
2024 January	54	31	85
2023 December	60	20	80
2023 November	86	31	117
2023 October	64	21	85
2023 September	56	27	83
2023 August	56	24	80
2023 July	38	39	77
2023 June	58	15	73
2023 May	80	156	236
2023 April	33	21	54
2023 March	67	16	83
2023 February	41	14	55
2023 January	40	27	67
2022 December	65	24	89
2022 November	51	27	78
2022 October	57	40	97
2022 September	44	23	67
2022 August	45	38	83
2022 July	40	44	84
2022 June	28	36	64
2022 May	37	30	67
2022 April	36	46	82
2022 March	43	33	76
2022 February	48	38	86
2022 January	36	38	74
2021 December	41	44	85
2021 November	34	27	61
2021 October	55	54	109
2021 September	45	25	70
2021 August	33	44	77
2021 July	36	33	69
2021 June	41	32	73
2021 May	49	40	89
2021 April	105	47	152
2021 March	50	63	113
2021 February	49	44	93
2021 January	47	28	75
2020 December	47	18	65
2020 November	44	17	61
2020 October	41	28	69
2020 September	42	16	58
2020 August	36	21	57
2020 July	34	16	50
2020 June	46	18	64
2020 May	57	19	76
2020 April	35	21	56
2020 March	37	16	53
2020 February	46	24	70
2020 January	46	24	70
2019 December	60	18	78
2019 November	38	30	68
2019 October	38	18	56
2019 September	43	22	65
2019 August	29	27	56
2019 July	36	29	65
2019 June	36	20	56
2019 May	48	33	81
2019 April	104	59	163
2019 March	65	31	96
2019 February	33	18	51
2019 January	55	42	97
2018 December	206	45	251
2018 November	342	22	364
2018 October	146	26	172
2018 September	79	18	97
2018 August	57	17	74
2018 July	45	20	65
2018 June	53	13	66
2018 May	62	23	85
2018 April	68	9	77
2018 March	45	8	53
2018 February	57	11	68
2018 January	63	5	68
2017 December	45	8	53
2017 November	88	14	102
2017 October	46	12	58
2017 September	81	20	101
2017 August	98	28	126
2017 July	100	16	116
2017 June	138	28	166
2017 May	166	31	197
2017 April	144	44	188
2017 March	145	15	160
2017 February	98	8	106
2017 January	92	15	107

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